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201Volume 27, Number 3 The Journal of Clinical Ethics
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
ABSTRACT
Moral distress has been covered extensively in the nursing
literature and increasingly in the literature of other health profes-
sions. Cases that cause nurses’ moral distress that are mentioned
most frequently are those concerned with prolonging the dying
process. Given the standard of aggressive treatment that is typical
in intensive care units (ICUs), much of the existing moral distress
research focuses on the experiences of critical care nurses. How-
ever, moral distress does not automatically occur in all end-of-life
circumstances, nor does every critical care nurse suffer its dam-
aging effects. What are the practices of these nurses? What spe-
cifically do they do to navigate around or through the distressing
situations? The nursing literature is lacking an answer to these
questions. This article reports a study that used narrative analysis
to explore the reported practices of experienced critical care nurses
who are skilled at and comfortable working with families and phy-
sicians regarding the withdrawal of aggressive treatment. A major
finding was that these nurses did not report experiencing the dam-
Moral Agency, Moral Imagination, and Moral
Community: Antidotes to Moral Distress
Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine
Terri Traudt, MBC, MA, is a Communications Consultant special-
izing in bioethics at the Center for Bioethics at the University of
Minnesota, in Minneapolis.
trau0116@umn.edu
Joan Liaschenko, PhD, RN, FAAN, is a Professor at the Center
for Bioethics and Nursing at the University of Minnesota.
Cynthia Peden-McAlpine, PhD, ACNS, BC, is an Associate Pro-
fessor in the School of Nursing at the University of Minnesota.
© 2016 by
The Journal of Clinical Ethics.
All rights reserved.
aging effects of moral distress as described in the nursing litera-
ture. The verbal communication and stated practices relevant to
this finding are organized under three major themes: (1) moral
agency, (2) moral imagination, and (3) moral community. Further,
a total of eight subthemes are identified. The practices that consti-
tute these themes and subthemes are further detailed and dis-
cussed in this article. Understanding these practices can help miti-
gate critical care nurses’ moral distress.
BACKGROUND
Moral distress has been recognized and studied
for more than 30 years. The concept was first intro-
duced in 1984 by philosopher Andrew Jameton, who
defined it as the feeling experienced “when one
knows the right thing to do, but institutional con-
straints make it nearly impossible to pursue the right
course of action.”1 Three years later, Judith M.
Wilkinson extended Jameton’s work by further ex-
ploring the phenomenon of moral distress as expe-
rienced by staff nurses working in hospitals.2 She
looked specifically at the kinds of cases that caused
moral distress for nurses and discussed both the
types of situations and moral frameworks involved.
The cases mentioned most frequently by the
nurse subjects were those concerned with prolong-
ing life. The moral issues mentioned most often were
(1) harm to the patient in the form of pain and suf-
fering and (2) treating persons as objects, or dehu-
Features
Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine, “Moral Agency, Moral Imagination, and Moral Community: Antidotes to
Moral Distress,”
The Journal of Clinical Ethics
27, no. 3 (Fall 2016): 201-13.
202 The Journal of Clinical Ethics Fall 2016
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
manizing them. Given these findings, it is no sur-
prise that much of the subsequent nurses’ moral dis-
tress research from 1987 forward focuses on experi-
ences in critical care settings.
Patricia Rodney was one of the first to further
moral distress research by examining the experience
specific to nurses caring for dying patients in criti-
cal care settings.3 The results of her study found
“senselessness” to be a central theme of critical
nurses’ perspectives on prolonging the dying pro-
cess. She found that these nurses experienced cor-
responding moral distress that resulted in feelings
of resentment, frustration, and sorrow.
Continued studies confirmed that the majority
of clinical situations reported to cause critical care
nurses to experience moral distress were related to
end-of-life care, and the highest levels of moral dis-
tress were found to be associated with providing
aggressive treatment to patients who were not ex-
pected to benefit from that provision.4 The reasons
nurses felt futile care was provided included de-
mands by patients’ family members, the lack of
timely or skilled communication, and the lack of
consensus among the treating team.5 In morally dis-
tressing situations related to the end of life, nurses
described negative consequences for themselves, pa-
tients, and families. For the nurses, these negative
consequences included psychological and physical
exhaustion, decreased morale, and decreased job
satisfaction.6
While previous studies acknowledged both the
institutional and individual components of moral
distress, there was little written that offered theo-
retical explanation of how these components were
related. Elizabeth Peter and Jean Liaschenko stud-
ied moral distress within the context of feminist
moral theory, concentrating on the work of Marga-
ret Urban Walker and Hilde Lindemann.7 Feminist
moral theory sees morality as a set of socially em-
bodied practices that occur between people as they
account to each other. Walker described moral iden-
tity as an accounting of what a person responds to,
takes responsibility for, cares for, and values.8 Un-
der this lens, Peter and Liaschenko described moral
distress as “the response to constraints experienced
by nurses specific to their moral identities, respon-
sibilities, and relationships.”9
Given the strong relationship between moral dis-
tress and aggressive end-of-life treatment, Peter and
Liaschenko argued that the goal of healthcare should
be one of healthcare professionals working together
in a shift away from prolonging life at all cost to the
relief of suffering.10 This shift is challenging in a
culture in which the boundary between not enough
treatment and too much treatment is difficult to es-
tablish.11 Perceptions vary between physicians,
nurses, and family members. More so than others,
critical nurses accept the reality of death and are
committed to making it as comfortable as possible,
despite the “paradigm of curing” rather than a “para-
digm of caring” that is prevalent in critical care en-
vironments.12
Critical care nurses have reported moderate lev-
els of moral distress overall.13 They cited organiza-
tional, professional, and emotional stressors.14 Emo-
tional stressors included value conflicts, lack of
emotional support, and dealing with the suffering
of patients and families. Professional stressors in-
cluded lack of end-of-life competencies, difficulty
communicating with families, and difficulty collabo-
rating with the medical team. Organizational stres-
sors included the lack of a palliative care approach,
inter-professional mistrust and conflict, and lack of
continuity in life support and treatment plans.
Moral distress has a negative impact on the
healthcare work environment. One study found that
one in three nurses experienced moral distress.15
Another study found that nearly 50 percent of nurses
have acted against their conscience in providing care
to terminally ill patients.16 Most critical care nurses
do not feel their nursing education prepared them
to provide quality care to the dying and their loved
ones.17
Since not every critical care nurse experiences
the damaging effects of moral distress, there is much
to be learned from the reported practices of those
who do not. Although rich in identifying the pres-
ence of moral distress in ICUs and its negative con-
sequences for nurses, the literature is lacking in in-
formation about those nurses who manage to avoid
or navigate through it. This article reports the sec-
ond major finding of a study of experienced critical
care nurses who are comfortable with dying patients,
which described their communication with families
and physicians to negotiate consensus on withdraw-
ing aggressive treatment and shifting to comfort
care.18 This finding concerns the apparent absence
of moral distress in the nurses. We document the
specific practices reported by these experienced
critical care nurses who were able to navigate around
or through morally distressing situations.
METHOD
Research Design
Narrative research interprets the meaning of ac-
tions and events experienced by individuals or
groups to describe why something happened as it
203Volume 27, Number 3 The Journal of Clinical Ethics
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
did.19 An understandable plot or story line is
achieved by linking together actions and events,
organizing them into a schematic whole. The over-
all plot is constructed by highlighting common ac-
tions and events, identified as themes. A hermeneu-
tic interpretive technique is used to analyze the data
and create the story from narrative examples that
construct the plots and themes.20 These plots and
themes explain the overall story. Narratives from
reported practices are valuable for illuminating ac-
tual practices.
Participants and Settings
A volunteer sample of 19 critical care nurses
participated in the study. These nurses represented
four ICUs located in a large teaching hospital in the
midwestern United States, including neurological,
medical, cardiovascular, and cardio-thoracic surgi-
cal units. The invitation to participate offered the
options of self-nomination or peer-nomination. All
participants were self-nominated.
Inclusion criteria for this study included a mini-
mum of five years’ experience, a work schedule of
at least half time, being comfortable with dying pa-
tients and their families, and having excellent com-
munication and pain and symptom management
skills. The average age of these nurses was 48, and
their critical care experience averaged 17 years. Of
the 19 participants, 13 (68 percent) reported they
had no education in death and dying. The remain-
ing six participants (32 percent) reported they had
education in death and dying through continuing
education programs.
Data Collection
Principal investigators collected the data be-
tween January and April 2012. All ICU nurses in
the teaching hospital were invited to participate by
letters in their mailboxes, and copies were also sent
to them via email. The letter detailed the study and
inclusion criteria and instructed interested nurses
to contact the researchers by telephone to schedule
an interview.
The data consisted of unstructured, audiotaped
interviews conducted by the principal investigators
that lasted approximately 90 minutes. Each partici-
pant was asked the following “grand tour” question:
“Tell me about stories where you were able to nego-
tiate with families and physicians to get everyone
on the same page regarding withdrawal of aggres-
sive treatment.” In the interview process, particular
attention was paid to the temporal structure of the
narrative to gather sequenced narrative informa-
tion.21 The researchers followed the lead the partici-
pant provided, asking clarifying questions through-
out the interview.
The research team used the consensual valida-
tion method22 and unanimously agreed that the 19
interviews provided sufficient data to answer the
research aim. This richness of the data was used as
the criteria for ending data collection. The interview
data provided ample material for numerous thick
descriptions.
The audiotaped interviews were professionally
transcribed into written text, and checked for accu-
racy of transcription. The written interviews were
subsequently coded in ATLAS.ti, a computer soft-
ware program designed to facilitate qualitative data
analysis and research.
Ethical Considerations
The institutional review boards at the research-
ers’ university and the teaching hospital where the
nurse participants were recruited approved the
study. Participants provided written informed con-
sent prior to their interview, and were paid an hono-
rarium of US$100 for their time. Each nurse was
assigned a fictitious name for recording, transcrip-
tion, and coding to ensure confidentiality. The de-
identified transcripts were then stored in electroni-
cally encrypted files in a locked office.
Data Analysis
The data were analyzed using a narrative, herme-
neutic interpretive approach. The research team
used the consensual qualitative research method, in
which each researcher analyzes the data indepen-
dently, followed by analysis by a team. The focus of
the analysis is interpretive, and discussion moves
between the original data and the emerging descrip-
tion of the plot and themes.23
In the interpretive process, it became clear that
the nurse participants in the study did not demon-
strate evidence of experiencing moral distress as
described in the nursing literature. This subset of
data was then further analyzed. The verbal commu-
nication and stated practices relevant to this find-
ing were identified and categorized, first as plots,
then abstracted to themes. Descriptions were writ-
ten for each theme, and exemplars for each theme
were selected to illustrate the descriptions. The ac-
tions and events that were interpreted as themes
were identified and reported as three major themes
and eight subthemes.
Rigor
Narrative researchers have argued for acceptance
of the validity of collected evidence and interpreta-
204 The Journal of Clinical Ethics Fall 2016
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
tion that is foundational to narrative analysis. The
purpose of validation is to convince readers that the
research assertions are strong enough to be a basis
for understanding human behavior.24 The researcher
is responsible for ensuring that the participant’s own
voice is heard and the narrative is not primarily the
interviewer’s creation.25
Yvonne S. Lincoln and Egon G. Guba proposed
four criteria for establishing trustworthiness in a
qualitative study: (1) credibility, (2) dependability,
(3) confirmability, and (4) transferability.26 In later
writings, they established authenticity as a fifth cri-
terion.27 All five of these criteria were met in analy-
sis of the data in this study.
In this study, trustworthiness was ensured by
the audiotaped interviews and their verbatim tran-
scription. The professionally transcribed interviews
were reviewed and further checked for accuracy by
the researchers. The group dynamic ensured reflex-
ivity, the process of examining both oneself as the
researcher and the research relationship. Research
team members made sure that one another’s precon-
ceptions did not influence interpretation.
This study, by using the same interview guide-
lines, careful documentation in ATLAS.ti, and the
use of memos, maintained dependability for an in-
quiry audit purpose. Inter-coder checks were estab-
lished, and category lists and themes were devel-
oped and managed via ATLAS.ti. Based on the nar-
ratives, thick, vivid descriptions were constructed
and followed by illustrative data. It is the thick de-
scription in the findings that allow transferability
to like contexts. The researchers mutually agreed
that a point of data saturation had been reached be-
cause the team was no longer finding new informa-
tion relevant to the themes.
FINDINGS
Enacting moral agency, exercising moral imagi-
nation, and fostering moral community were the
major themes that described how experienced criti-
cal care nurses navigated around or through mor-
ally distressing situations while working with fami-
lies and physicians regarding the withdrawal of ag-
gressive treatment. The specific practices that con-
stituted these themes include: self-awareness, ad-
vocacy, empathy, ascertaining what the patient
would want, envisioning and facilitating possibili-
ties for a good death, supporting relationships, man-
aging conflict, and doing moral communicative
work. These practices are non-sequential and are
often circular. However, each is discussed separately
in this article for the sake of clarity (see table 1).
Theme One: Moral Agency
Moral agency is commonly defined as an
individual’s ability to make a moral judgment based
on a commonly held notion of right and wrong and
to be held accountable for their actions. Nurses in
this study shared stories that demonstrated strong
moral agency that facilitated positive outcomes for
both patients and their family members. The nurses
consistently approached the moral issues embedded
in their daily work in a caring manner with a pri-
mary focus on loyalty to their patients and a will-
ingness to challenge hierarchies. They held them-
selves accountable for their actions and did not fail
to act because of either external or internal con-
straints. The practices of (1) self-awareness, includ-
ing accountability for self and one’s skill, and (2)
advocacy fostered their ability to work through these
constraints.
Self-awareness. To be self-aware is to be con-
scious of factors that influence one’s thoughts, feel-
ings, and actions so that one has a reasonable idea
of how and why one thinks, feels, and acts as one
does. The nurses in this study understood and were
able to articulate what it was about themselves that
contributed to their skill and comfort working with
families and physicians regarding the withdrawal
of aggressive treatment. They knew the work of nurs-
ing, knew how to get the work done, and understood
what makes them skilled. They clearly articulated
their roles and responsibilities as they and others
understood them, and held themselves accountable
for their actions. They benefited from their own ex-
perience as did others. There were two aspects to
their self-awareness: accountability for self as a
moral agent in general and as a nurse in particular,
and accountability for their skill, discussed below.
Accountability for self was the first component
of the nurse participants’ self-awareness. These
nurses articulated their understanding of what it
TABLE 1. Themes and specific practices
1. Moral agency
• Self-awareness
• Advocacy
2. Moral imagination
• Empathy
• Ascertaining what the patient would want
• Envisioning and facilitating possibilities for good death
3. Moral community
• Supporting relationships
• Managing conflict
• Moral communicative work
205Volume 27, Number 3 The Journal of Clinical Ethics
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The Journal of Clinical Ethics.
means to be a nurse and their willingness to accept
responsibility for whom and for what is under their
care. The responsibility they accepted was for the
(1) professional knowledge and skills necessary to
be a competent nurse, (2) knowledge and under-
standing of their own moral values, and (3) knowl-
edge of their emotions and how their emotions in-
fluence their actions. They knew the emotional work
involved in caring for the dying and recognized the
need to manage the difficulties of the work. They
were concerned not only with their own ability to
manage the stress and complexity of working with
dying patients, but also with how their colleagues
managed this work. One participant described her
concern this way:
Irene: I sometimes feel like nurses are different
from the rest of the public because of what we
experience at the bedside. . . . It worries me. I
feel like I have coped with it very well, but who
are we missing that takes it home and can’t fig-
ure out how to bring it in their heart or how to
release it?
Interviewer: And what’s the “it” you’re coping
with?
Irene: When you value life and it’s ended . . . it’s
been a traumatic end and you’re seeing this hap-
pen in front of your very eyes. You’re caring for
that patient and trying to make it [the death] the
best possible way and then you wrap him in a
body bag, you zip him up, and call transport to
take him to the morgue. You continue to do your
job. . . .
The nurses benefited from their own experience
and learned from that of others. They accepted re-
sponsibility for their particular stance on end-of-life
care and recognized that people held different views.
They cited the virtue of “wisdom” and the qualities
of “confidence,” “maturity,” and “sensitivity” as
important personal traits in doing this work well.
As one nurse commented:
It’s all in maturity and sensitivity, and respect-
ing that we all have different perceptions and
values, and we don’t always have the right to
put them onto other people. That’s hard and it
takes a lot of wisdom. [Irene]
Not only did these nurses take responsibility for
what they knew, they recognized what they didn’t
know, and knew how to get the information they
needed to act. A participant displayed this aware-
ness and understanding in stating:
You need to know what you know. You need to
know what you don’t know. You need to know
where to go to get the answers to the stuff you
don’t know. It’s that simple. Nobody is ever go-
ing to have all the answers. . . . Just be able to
recognize what you know and share it. And be
able to recognize when you don’t know and say
“I don’t know.” Those are not dirty words.
[Anne]
Accounting for skill was the second component
of the participants’ self-awareness. Here they were
not referring to their clinical skills, but rather to
communicative skills such as listening, interpret-
ing body language and emotion, timing, and word
choice. Many attributed this practical wisdom to
longevity in their position and unit and learning
from repeated experiences. A significant part of this
development was learning from one another through
the mutual sharing of experiences that also included
feedback. One nurse described it this way:
Having a comfort level, being very close to some-
one you don’t know at that most intimate mo-
ment when you’re with someone who is maybe
taking their last breath, how did I learn to do
that except for experience and time? I wasn’t
taught that [formally]. I had situations. . . . Talk-
ing out loud sometimes is how you learn and
also, because I share a story that reminds me of
a story you’re telling, then we learn from each
other. . . . We teach each other without knowing
about it. We observe each other. [Irene]
Advocacy. For the nurses in this study, the prac-
tice of advocacy was central to their moral sense of
self and thus their moral agency. Their advocacy
included speaking to the family on behalf of the
patient and speaking to the medical team on behalf
of the family on end-of-life matters. In these situa-
tions, nurses reported advocating for their patients
by challenging families, physicians, or both to con-
sider a change of direction from aggressive treatment
to comfort care. To accomplish this they listened
carefully, skillfully asked questions about families’
and physicians’ understanding of the situation and
goals of care, and provided information. This com-
municative work kept the biographical life of the
patient and that person’s suffering body at the cen-
ter of concern. The following nurses stated the im-
portance of keeping the focus on the biographical
life of the patient when speaking on behalf of the
patient to the family:
I will remind them [the family] that this is about
what Mary the patient wanted and what kind of
things did Mary do? Was she real active? Was
she this? Was she that? What would she think
206 The Journal of Clinical Ethics Fall 2016
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
about being on a ventilator and in a nursing
home for an extended period of time, if not for
the rest of her life? [Anne]
Because you know, it is about family, but it isn’t
about family. It’s about what is best for that pa-
tient. And I think a lot of times with family mem-
bers, they’re thinking about what’s best for them.
But I’ve always got to remember that you’ve got
to think, “What is best for her?” What is best for
her may not be what is best for you. Family
members may want the mother to live forever,
but that’s not what’s best for her and especially
family members that have a little bit of guilt.
[Elaine]
Theme Two: Moral Imagination
Moral imagination is a moral agent’s active at-
tempt to consider what moral decisions to make and
what action to take. Strong moral imagination was
an attribute of the nurses in this study. For them, it
was a moral imperative to envision possibilities for
a “good death” for each individual dying patient. In
the context of considering withdrawal of aggressive
treatment, the stories they shared demonstrated their
ability to discern various possibilities for acting and
to envision the associated benefits and harms. The
specific practices the nurses discussed around moral
imagination were (1) empathy, (2) ascertaining what
the patient would want, and (3) envisioning and fa-
cilitating moral possibilities for a good death.
Empathy. Nurses’ empathy for the patient and
the family was key in helping families to make the
transition from aggressive treatment to comfort care.
The nurses in this study demonstrated their ability
to figuratively put themselves in another’s shoes and
skillfully reflect that perspective to the family. They
frequently cited aggressive treatment situations in
which they asked loved ones “How would you feel
if . . . ?” and “What would you want done if . . . ?”.
They shared stories that demonstrated reflective lis-
tening (offering back the speaker’s idea to confirm
their own understanding), thereby building trust,
respect, and a safe environment conducive to deci-
sion making. This empathetic communicative work
was a moral imperative for these nurses. As one par-
ticipant indicated:
It was a tremendous outlay of energy on my part,
but a lot of times when I’m working I’m think-
ing, if these people were my family, what would
I want someone to do for them? How much
would you put yourself out? How much does
somebody help the ones that you love at the end
of their life? [Ruby]
Empathy was also important so that nurses would
not get lost in the routine of their work in which
death was a significant part. Another participant
shared:
Sometimes I think we’ve been through this so
many times, but it’s always that person’s first
time, so just go in, not being all-knowing. . . . I
try to put myself in that family member’s shoes
and not say too much. Not to give too much ad-
vice, but rather just empathize with how hard
this must be. [Olivia]
Ascertaining what the patient would want. In a
medical culture where respect for autonomy and
shared decision making have replaced traditional
paternalism, unilateral withdrawal of aggressive
treatment by physicians is not the norm. Today it is
more common for families to demand further aggres-
sive interventions, even when such treatment is not
in the patient’s best interest. Under such circum-
stances, it was important to the nurses in this study
to ascertain what the patient would want.
The concept of ascertaining what the patient
would want must be situated in the context of the
larger study, which examined the communicative
work that nurses do with families and physicians
regarding the transition from aggressive treatment
to comfort care. None of the nurse participants told
a story of advocating for continued aggressive treat-
ment when either families or physicians wanted to
withdraw treatment. All of their narratives demon-
strated their conviction that withdrawal of aggres-
sive treatment and support of as peaceful a death as
possible was in the best interest of the patient. In
this study, ascertaining what the patient would want
was not about getting an answer to questions of a
technical sense—Would your family member want
to have CPR or not?—but rather about answers to
questions of an existential sense—What would it
mean for your family member to live “like this”?
One nurse shared:
If I can’t talk to the patient, I will talk to the
family and say, “Have you had a discussion with
your loved one regarding what they would want
as far as ongoing care for medical things?” Very
often they will say, “Well, they just want to live,”
or they’ll say, “Yes, Mom has been very clear to
me that she does not want to be on the ventila-
tor again,” . . . or whatever it may be. [Fran]
In helping families to explore the meaning of
“like this,” the nurses used knowledge of the
patient’s biographical life and deteriorating status
in attempt to show families that continued aggres-
207Volume 27, Number 3 The Journal of Clinical Ethics
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The Journal of Clinical Ethics.
sive treatment would not contribute to their loved
one’s flourishing.
A major way of helping families was to relieve
them of the responsibility for authorizing with-
drawal of aggressive treatment by reassuring them
that they were not acting on their own, but rather as
an important voice for their now-voiceless loved one.
One nurse shared how she defended her patient’s
best interests by reminding family members of their
appropriate role in decision making:
I’m not asking them to decide what they would
want; I’m asking them to tell me what they know
the patient wanted. It’s important to me to make
that distinction for them because it’s important
that the decision made is about what the patient
wanted and it also gives them some absolution,
if you will, of responsibility for the decision that
they need to voice. [Anne]
Envisioning and facilitating moral possibilities
for a good death. The nurses in this study sought to
ensure that their patients’ lives ended well and that
the patients’ deaths were morally acceptable and
emotionally comfortable for their families. The
nurses saw alternate ways of viewing a patient’s
imminent death. They often challenged families and
physicians to consider whether continued aggres-
sive treatment was sustaining life or prolonging suf-
fering. One participant stated:
I guess it’s how you want to view it. Do you want
to view it that we can prolong your life or that
we can prolong your suffering? We [ICU nurses]
view it, a lot of times, as we can prolong your
suffering. We would, quite often, choose to end
aggressive treatment much sooner than family
members will. And even physicians sometimes
too, just don’t quit. They are so aggressive and
the prognosis is so poor. [Natalie]
This presentation of an alternate view was im-
portant in helping families and physicians to come
to a mutual understanding of what was happening
to the patient. Working to provide a good death in-
volved transitioning from hope for a cure or a miracle
to realization that death was inevitable. It was a
moral imperative for these nurses to help families
remember their loved one’s death as peaceful. The
following participants shared how they worked to
facilitate this and prepare families for the emotional
work of grieving:
The first thing I think to do is make them [the
patients] look like the last hour wasn’t a struggle,
breathing tube or bleeding or messy. . . . So the
first thing we did we just got him washed up
and cleaned. I said to bring the family in and I
had no words. I didn’t have any words. I just
said, I’m so terribly sorry. [Jenny]
If I’m insensitive or not paying attention, that is
what they are going to remember about their fam-
ily member’s last days or last moments. Those
moments are often imprinted in people’s minds
and I want that to be the very best situation it
can possibly be. On our end I want to do every-
thing to make it good. I want them to feel at peace
about whatever is happening. [Maria]
Theme Three: Moral Community
A moral community is a group of people work-
ing towards a common moral end. The nurses in this
study indicated strong awareness of the importance
of moral community and saw themselves as critical
to the process of decision making regarding the with-
drawal of aggressive treatment. For these nurses, the
moral end sought was a good death for their patient.
They thought it was important for physicians to
share in the pursuit of this moral end. The nurses
reported practices that recognized and positively
utilized the relational nature of moral community.
The specific practices they demonstrated relevant
to moral community are (1) supporting relationships,
(2) managing conflict, and (3) moral communicative
work.
Supporting relationships. For the nurses in this
study, relationships were central to getting their
work done well. “Supporting” was a word used fre-
quently as they described themselves, their roles,
and responsibilities relative to forming and main-
taining relationships that made a moral community
possible. Recognizing the contributions of others to
the care of the patient and family was a way to es-
tablish and preserve their moral community.
On patient and family support, one participant
shared her perspective:
We always want to consider things through the
patient; what the patient would decide for their
self if they could. But they don’t live in isola-
tion; they live as part of this family. So I think
this [supporting the family] is extremely impor-
tant. [Fran]
Another shared her view on the importance of sup-
porting her fellow nurses:
I want her to know I’ve got her back. There’s
nothing stupid she can say. I’m here for her. . . .
I can’t make everyone do things my way, and I
wouldn’t want that, because I don’t think my
way is always perfect. Wisdom is being able to
208 The Journal of Clinical Ethics Fall 2016
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support, acknowledge, and give comfort to some-
one who is struggling or doubting what they said
and feeling like they made a mistake and try to
look at all the pieces to that and help them learn
from it. [Irene]
Another shared the importance of supporting phy-
sicians:
I feel they [the family] deserve to hear a pretty
good explanation from the physician, and then
what I do is I let the physician take the lead, or
I’ll talk to the physicians and just say this is
where we’re at, and I’ll just gently nudge them
into that position. “Here you go, let me know
when it’s good for you to talk to this family.”
Then they do so, and what I do is support the
physician. . . . I’ll support the physician, and I
feel that my role is to further educate them and
answer their questions and concerns. [Natalie]
Managing conflict. In the complexity of health-
care systems, conflict is inevitable, and this may be
especially the case when the moral stakes are high.
In spite of the inevitability of conflict, the nurses in
this study did not view it as insurmountable and
were skilled at staving it off or managing it to reso-
lution. In the stories the nurses shared, the major
underlying conflict was expressed as “Why are we
doing this [aggressive treatment for a dying patient],
and to what end?” This questioning directed the
work of the moral community.
The nurse participants’ narratives demonstrated
their ability to recognize conflict, identify its source,
minimize its impact, and manage the conflict to reso-
lution. They continually worked to achieve and
maintain positive relationships with families, phy-
sicians, and other team members. They saw com-
municative skill and patience as personal assets in
conflict management. The conflicts were with fami-
lies who did not want to acknowledge the deterio-
ration and implications of the patient’s condition,
and with physicians who did not want to give up on
aggressive treatment. The reasons for the conflict
included differences in values between quality of
life and quantity of life, the timing of withdrawal of
treatment, and incongruent communication from
different sources. Nurses described managing con-
flict as follows:
There are families who, if you try to talk to them
about the reality of the illness, any deteriora-
tion, or anything that has to do with [the pa-
tient] not living, they just don’t want to hear it.
All they want to do is keep going no matter what,
even though you have conversations with them
about quality of life. That gets difficult and they
get angry. [Bonnie]
Usually the conflict is with the family or the
physicians. A lot of times it is with the physi-
cians. . . . I shouldn’t stereotype, but sometimes
they just don’t want to let go. A lot of times they
just want to avoid the issue. [Elaine]
The nurses shared examples of everyday practices
that demonstrated their skill in minimizing impact
and managing the conflict to resolution. Part of man-
aging conflict is about understanding the reasons
for actions and determining if they make sense. To
achieve this, the nurses utilized the communicative
skills of asking questions in an effort to understand
the other person’s perspective, and respectful lis-
tening. This communicative work enabled the nurses
to protect and maintain relationships.
Situations of potential conflict, which are often
the result of communication failure, were compli-
cated by the common problem of families getting
different information from different physicians. The
nurses in this study were proactive in seeking reso-
lutions by not being afraid to “speak up” regarding
the problem and the need for resolution. A partici-
pant shared:
If the family expresses to me, “Gosh, we hear
one thing from someone, one thing from some-
one else,” I will tend to say, “I’m sorry. I’m go-
ing to get this clarified for you, so we can all get
on the same page.” Then I go straight to the phy-
sicians and say, “What’s the plan? The family is
confused. They are in a huge challenge.” [Jenny]
Another study participant recognized that fam-
ily members often need time to come to terms with
the knowledge that their loved one is dying. She
shared the value of patience in pro-actively manag-
ing potential conflict and “getting people on the
same page”:
How I deal with that basically is just to ask them
why they feel the way they do and let them pro-
cess it. Sometimes it takes two or three days for
them to process. It’s usually not just a process
of “Okay, fine, yeah, we’ll do that.” It usually
takes a while. We usually have a couple of con-
ferences with the family, with the doctor, and
bring in some other doctors, sometimes bring-
ing palliative care into the conference. . . . I think
the benefit from the conference is that every-
one is together; everyone hears the same thing,
and the doctors can answer the questions the
family has. [Elaine]
209Volume 27, Number 3 The Journal of Clinical Ethics
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The Journal of Clinical Ethics.
Moral communicative work. A good death, one
that is free from avoidable distress and suffering for
patients, their families, and caregivers, is not pos-
sible without good communication. The nurses in
this study demonstrated skill in moral communica-
tion: the verbal and nonverbal social interaction that
enhances one another’s understanding of the moral
situations they are in and informs moral decision
making and action. The nurses shared stories that
demonstrated their skill in establishing rapport, pre-
paring for conversations, asking questions, active
listening, giving reflective feedback, being clear, and
knowing when not to speak. The following quotes
from participants in the study illustrate this work:
You start off with developing rapport. In the ICU,
you have to do it quickly. If you develop rap-
port within the first few minutes of meeting
somebody, it holds for the shift. You need to be
able to build that trust right away. So you start
with the family members, feel them out to see
where they’re at. “How are you doing with all
this? Is there anything you’d like to talk about?
What have the doctors been telling you about
how things have been going?” . . . Then summa-
rizing for them where the patient’s at currently,
like, “The patient came in really sick. This is
what we’re seeing right now,” gently telling them
the information. [Pam]
Wise nurses are good listeners, and they do more
listening than speaking. Sometimes you can in-
tervene without saying anything. Sometimes by
being a good listener, the person all of a sudden
comes up with a discovery of what they were
looking for because they either see it in your face
or they heard themselves say it out loud, and
suddenly it opens a door to something else they
think about. I see that quite frequently. Some-
times that is wisdom, knowing when to let some-
one make a discovery for him- or herself. [Irene]
DISCUSSION
This study extends the nursing literature on
moral distress by reversing the focus from the causes
and implications for critical care nurses to the re-
ported practices of those who do not appear to ex-
perience its damaging effects. Although not asked
directly about moral distress, the nurses in this
study—who are skilled at and comfortable working
with families and physicians regarding the with-
drawal of aggressive treatment—did not show evi-
dence of experiencing moral distress in the midst of
commonly distressing situations. These nurse par-
ticipants reported practices that appear to function
as safeguards against its negative consequences. The
narrative analysis of the stories they shared illus-
trates that experienced critical care nurses working
with dying patients can navigate around or through
distressing situations without the consequent moral
distress by enacting moral agency, exercising moral
imagination, and fostering moral community.
Moral Agency
The first antidote for critical care nurses’ moral
distress is moral agency. The nursing literature
speaks much of empowerment, but little of moral
agency. Yet nurses are moral agents; they must have
agency in order to influence relationships and out-
comes in their workplace. We argue for replacing
the concept and language of “empowerment” with
that of “moral agency.”
The concepts of empowerment and moral
agency are not unrelated. However, empowerment
implies authorization or permission to act, whereas
agency implies self-directed capacity or choice to
act. Clearly this difference has moral significance.
The nurses in this study did not need to have their
actions authorized or legitimated by others—they
took responsibility and held themselves accountable
and did not fail to act because of either external or
internal constraints.
The critical care environment for this study did
not appear to be unlike other ICUs where nurses have
reported experiencing moral distress. Yet, the causes
of moral distress reported in the literature were ei-
ther not expressed or were overcome by the study
nurses. For example, a frequent source of moral dis-
tress for critical care nurses that is cited in the lit-
erature is a lack of input on end-of-life decision
making. The nurses in this study saw themselves as
active moral agents with not just a key role, but in
fact a responsibility to facilitate end-of-life discus-
sions. They demonstrated skill in moral communi-
cation, the verbal and nonverbal social interaction
that enhances understanding of moral situations,
informs moral decision making, and facilitates moral
action. They worked to establish and maintain moral
communities, asserting themselves as essential to
the process of decision making regarding the with-
drawal of aggressive treatment and the actions nec-
essary to foster a “good death,” the moral end sought.
(The nurses’ descriptions of their work contribut-
ing to a “good death” was consistent with Marilyn J.
Field and Christine K. Cassell’s definition as “one
that is free from avoidable distress and suffering for
the patients, families and caregivers; in general ac-
cord with the patients’ and families’ wishes; and
210 The Journal of Clinical Ethics Fall 2016
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reasonably consistent with clinical cultural and ethi-
cal standards.”28)
The nurse participants in this study shared com-
mon characteristics of what we have termed “ac-
countability for self,” a component of self-awareness.
The study findings demonstrate the relationship
between self-awareness and what the feminist philo-
sophical literature describes as moral identity. For
Margaret Urban Walker, moral identity is an account-
ing of what a person takes responsibility for, re-
sponds to, is concerned about, cares for, and val-
ues—this is moral agency.29
The other component of self-awareness we
termed “accounting for skill.” The nurses in this
study were adept at this. Many attributed their skill
to longevity in their position and unit and learning
from repeated experiences, which they also shared
with one another. Previous studies have reported
correlations between years of experience and moral
distress, but the findings are inconclusive.30 In a 2005
study of critical care nurses, Ellen H. Elpern and
colleagues found that intensity of moral distress in-
creased with years of nursing experience.31 This led
the authors to speculate that with increasing years
in the profession the cumulative effect of distress-
ing experiences increased as well. On the other hand,
Katherine A. Hinderer found that increased years of
experience with patients’ deaths was a major ele-
ment in critical care nurses’ coping skill.32 Our study
confirms Hinderer’s findings. We believe this is be-
cause the nurses were able to form and sustain moral
communities, another antidote to moral distress that
is discussed further below.
Moral Imagination
The second antidote to moral distress in critical
care nurses is moral imagination. Moral imagina-
tion requires not just the skill of being able to imag-
ine various possibilities and their consequences, but
the ability to morally evaluate the possibilities as
well. This is not a new concept. P. Anne Scott de-
fined moral imagination as “that aspect of the imagi-
nation that potentially becomes active in the moral
agent’s attempt to consider what moral decisions to
make.”33 Mary C. Corley, drawing on Scott’s work,
argued that nurses who have an acute moral imagi-
nation are more likely to have a high level of moral
sensitivity and moral competence, and experience
less moral distress.34 This study supports Corley’s
work and adds the specific practices by which moral
imagination is demonstrated. These practices in-
clude empathy, ascertaining what the patient would
want, and envisioning and facilitating moral possi-
bilities for a good death.
Knowing the patient was absolutely critical to
these nurses. Having empathy for the embodied suf-
fering of the patient and knowing the biographical
life of the patient were the ways they ascertained
what the patient would want by helping families
answer the question, “Would your loved one want
to live like this?” When families can see the bio-
graphical life of their loved one being respected and
honored by the transition from aggressive treatment
to comfort care, the likelihood of a good death—the
moral end that is sought—is made possible.
Moral Community
Fostering moral community is the third antidote
to the moral distress experienced by critical care
nurses. A moral community is a group of people
united by a shared common end with moral impli-
cations: in this case, the well-being of patients. Work-
ing for the well-being of patients by many people
and groups requires sustained coordination of ac-
tion across these people and groups. Relationships
that allow for questioning, that can tolerate the ex-
pression of uncertainty, and that are frequently ac-
companied by strong affect are essential to coordi-
nating this work. Recognizing the contribution of
others and being able to call attention when these
things are lacking reinforces the goal of the work
and minimizes disruption of the work. The nurses
in this study were expert in supporting relationships
that foster a moral community.
It is important to note that communities typi-
cally reflect multiple ends, at least some of which
will inevitably conflict. For this reason, managing
conflict is an essential skill for working in a com-
plex social world. Differing perspectives regarding
end-of-life care are a major cause of conflict and
moral distress in critical care nurses. The practice
of managing conflict is intertwined with being a
skilled communicator. A study that examined fam-
ily members’ responses to making choices regard-
ing the withdrawal of aggressive treatment found
that conflict was the result of their unmet needs for
information and communication.35 The data suggest
that a shift from aggressive treatment to comfort care
was often perceived by patients’ family members as
abrupt and unexplained, and contributed to conflict.
The narratives shared by the nurses in this study
support that finding. However, the study nurses uti-
lized the communicative skill of asking questions
and respectful listening in an effort to understand
family members’ perspectives and needs in the face
of decision making regarding the withdrawal of ag-
gressive treatment, thereby minimizing the poten-
tial for conflict.
211Volume 27, Number 3 The Journal of Clinical Ethics
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The Journal of Clinical Ethics.
A study that described the stressors experienced
by critical care nurses in providing end-of-life care
found that professional stressors included difficulty
in collaborating with physicians as well as difficulty
in communicating with families.36 The practice of
moral communicative work is not only important
to offsetting these stressors, it underlies every other
specific practice previously discussed.
Feminist healthcare ethics recognizes the work
of nurses as embedded in complex social networks
including healthcare providers, patients, families,
administrators, and others further organized under
political and economic structures.37 Historically,
these networks have been structured in strict hier-
archies that are marked by differences in power and
knowledge. Today the emphasis is on teamwork in
an attempt to reduce these hierarchical differences
and recognize the contributions of all involved in
patient care. As laudable as this effort is, we argue
that the notion of a team and of teamwork lacks the
moral connotation that health work deserves. The
notion that healthcare environments are moral com-
munities rather than hierarchical organizations has
been increasingly recognized as imperative to good
patient care and end-of-life decision making.38 In
terms of moral distress, this is particularly impor-
tant in caring for the dying. We argue for replacing
the concept and language of “teamwork” with that
of “moral community.”
LIMITATIONS
The study was limited because the practices
identified were based on the participants’ self-re-
porting rather than observed, real-time behavior. It
was also limited by the participants’ self-selection
and lack of diversity. The study group was all fe-
male, with an average age of 48 years. The findings
are not necessarily reflective of the demographics
of a larger, more diverse ICU. Further, the study was
limited to one midwestern teaching hospital in a ma-
jor city.
CONCLUSION
As medical technology continues to expand our
capability to prolong life, extending the dying pro-
cess is a potential complication. The line between
too little and too much treatment is increasingly
blurred. Continued attention to the consequent
moral distress is necessary. Healthcare moral com-
munities can benefit from the knowledge gleaned
from this study and its implications for reducing
moral distress in critical care nurses.
Given that few nurses in this study had formal
education regarding death and dying, we believe
their education had little impact on their ability to
navigate around or through morally distressing situ-
ations. These nurses spoke a great deal of support-
ing each other and supporting newer nurses. This
speaks to the value of mentorship.
A feminist moral perspective contributes two
important insights. One is that moral issues do not
stand outside of their social contexts. The problems
of morality are embedded in everyday work. The
second insight is that humans are intrinsically rela-
tional and interdependent, which emphasizes the
significance of connection, sharing, and commu-
nity.39 A feminist lens supports a shift in thinking
and language away from empowerment toward
moral agency and from teamwork toward moral com-
munity. The advantage of this language is to high-
light the morality that is embedded in day-to-day
nursing work and the ways in which nurses under-
stand their moral identity, relationships, responsi-
bilities, and values.40
The findings of this study are valuable in pro-
viding illumination and exemplars for what expert
practice in caring for patients who are transitioning
from aggressive treatment to comfort care actually
looks like. Because these practices are identifiable,
we assume they are replicable. We suggest that in-
terventions that are designed to mitigate moral dis-
tress use these concepts and language. The devel-
opment of critical care nurses who are able to navi-
gate around or through morally distressing situations
can be achieved through mentorship in moral
agency, moral imagination, and the fostering of moral
communities.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
We thank Elizabeth Epstein, PhD, RN, and Elizabeth
Peter, PhD, RN, for their thoughtful review of an earlier
draft of this article.
NOTES
1. A. Jameton, Nursing Practice: The Ethical Issues
(Englewood Cliffs, N.J.: Prentice-Hall, 1984).
2. J.M. Wilkinson, “Moral Distress in Nursing Prac-
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3. P. Rodney, “Moral Distress in Critical Care Nurs-
ing,” Canadian Critical Care Nursing Journal 5, no. 2
(1988): 9-11.
212 The Journal of Clinical Ethics Fall 2016
Articles from
The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
4. E.H. Elpern, B. Covert, and R. Kleinpell, “Moral
Distress of Staff Nurses in a Medical Intensive Care Unit,”
American Journal of Critical Care 14, no. 6 (2005): 523-
30; B.R. Ferrell, “Understanding the Moral Distress of
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7. E. Peter and J. Liaschenko, “Moral Distress Reex-
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8. M.U. Walker, Moral Understandings: A Feminist
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9. Peter and Liaschenko, “Moral Distress Reexam-
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10. Ibid., 343.
11. S.R. Kaufman, Ordinary Medicine: Extraordinary
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13. Elpern, Covert, and Kleinpell, “Moral Distress of
Staff Nurses,” see note 4 above.
14. C. Gélinas, L. Fillion, M. Robitaille, and M.
Truchon, “Stressors Experienced by Nurses Providing End-
of-Life Palliative Care in the Intensive Care Unit,” Cana-
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man Sciences (Albany, N.Y.: SUNY Press, 1988).
20. Ibid.; D.E. Polkinghorne, “Validity Issues in Nar-
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86.
21. Polkinghorne, Narrative Knowing and the Human
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Guide to Conducting Consensual Qualitative Research,”
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“Understanding Human Action through Narrative Expres-
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of Inquiry for Nursing, ed. E.P. Chinn (Gaithersburg, Md.:
Aspen, 1994), 41-58.
24. P.H. Bailey, “Assuring Quality in Narrative Analy-
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Harvard Educational Review 60, no. 4 (1990): 415-43;
Polkinghorne, Narrative Knowing and the Human Sci-
ences, see note 19 above.
25. Ibid.
26. Y.S. Lincoln and E.G. Guba, Naturalistic Inquiry
(Newbury Park, Calif.: Sage, 1985).
27. E.G. Guba and Y.S. Lincoln, “Competing Paradigms
in Qualitative Research,” in Handbook of Qualitative Re-
search, ed. N.K. Denzin and Y.S. Lincoln (London: Sage,
1994): 105-117.
28. M.J. Field and C.K. Cassel, Approaching Death:
Improving Care at the End of Life (Washington, D.C.: Na-
tional Academies Press, 1997).
29. Walker, Moral Understandings: A Feminist Study
in Ethics, see note 8 above.
30. Elpern, Covert, and Kleinpell, “Moral Distress of
Staff Nurses,” see note 4 above; K.A. Hinderer, “Reactions
to Patient Death: The Lived Experience of Critical Care
Nurses,” Dimensions of Critical Care Nursing 31, no. 4
(2012): 252-9.
31. Elpern, Covert, and Kleinpell, “Moral Distress of
Staff Nurses,” see note 30 above.
32. Hinderer, “Reactions to Patient Death,” see note
30 above.
33. P.A. Scott, “Emotion, Moral Perception, and Nurs-
ing Practice,” Nursing Philosophy 1, no. 2 (2000): 123-33.
34. M.C. Corley, “Nurse Moral Distress: A Proposed
Theory and Research Agenda,” Nursing Ethics 9, no. 6
(2002): 636-50.
35. S.A. Norton et al., “Life Support Withdrawal: Com-
munication and Conflict,” American Journal of Critical
Care 12, no. 6 (2003): 548-55.
36. Gelinas et al., “Stressors Experienced by Nurses,”
see note 14 above.
37. Peter and Liaschenko, “Moral Distress Reexam-
ined,” see note 7 above.
38. M.A. Aroskar, “Envisioning Nursing as a Moral
Community,” Nursing Outlook 43, no. 3 (1995): 134-8; L.B.
Hardingham, “Integrity and Moral Residue: Nurses as Par-
ticipants in a Moral Community,” Nursing Philosophy 5,
no. 2 (2004): 127-34; W. Austin, “Moral Distress and the
Contemporary Plight of Health Professionals,” HEC Fo-
213Volume 27, Number 3 The Journal of Clinical Ethics
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The Journal of Clinical Ethics
are copyrighted, and may not be reproduced, sold, or exploited
for any commercial purpose without the express written consent of
The Journal of Clinical Ethics.
rum 24, no. 1 (2012): 27-38.
39. Walker, Moral Understandings, see note 8 above.
40. E. Peter, A. Simmonds, and J. Liaschenko, “Nurses’
Narratives of Moral Identity: Making a Difference and Re-
ciprocal Holding,” Nursing Ethics (24 May 2016): doi
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