older person who is close to death; and a woman with cancer
who has been vomiting all day and is in severe pain. You
know you cannot meet everyone’s needs well. How do you
‘distribute’ your nursing care? (You really like the person
who is going home in the morning.)
Supporting consent
A resident is attempting to perform a spinal tap on an ado-
lescent whom you know dislikes the resident. After one
failed attempt, the adolescent tells the resident to stop. The
resident asks you to administer an anti-anxiety medication
to the person so the resident can get the spinal tap done
quickly. Should you administer the medication, knowing the
patient no longer consents to the procedure?
Conflicts between the person’s and clinician’s interests
Community nurses are taking turns being assigned to care
for new people who test positive for the human immuno-
deficiency virus (HIV). One nurse, who is breastfeeding her
8-month-old infant, refuses to take her turn, fearing she will
transmit the disease to her baby. The other nurses tell her she
must accept the assignment of this HIV-positive patient
because none of them is willing to take her turn. What erro-
neous assumptions are the nurses making, and is a nurse
ever justified in refusing to care for a person?
Conflicts concerning the appropriate use of technology
An infertile woman asks you what you think about in-vitro
fertilisation. She tells you she is ‘desperate to produce a
child for her husband and in-laws’, but also has grave reser-
vations about the whole process: ‘I’ve read about couples
who end up with seven frozen embryos, and I think that
would kill me, thinking I’ve got seven potential kids on ice.’
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Chapter 11 Values, ethics and advocacy
Nurses, midwives and doctors
Nurse/midwife–doctor situations can also result in ethical
distress for nurses. Common problems include disagree-
ments about a proposed medical regimen, conflicts regarding
the scope of the nurse’s role, and doctor incompetence.
Disagreements about the proposed medical regime
In the nursing home where you work, any client who loses
a significant amount of weight (more than 10% of usual
body weight) is automatically subjected to an exhaustive
battery of tests (including a complete gastrointestinal [GI]
series) to determine whether there are any physical causes
for the weight loss (e.g. a tumour). You strongly object to
one client being put through these tests because she has
made it clear she wants to die and will starve herself to death
if that is the only way she can do it. The medical director
insists the person undergoes the diagnostic studies because
there is a long history of family dissatisfaction with the
facility’s medical care. The director wants to avoid causing
further dissatisfaction. Are you responsible for preparing the
client for these diagnostic studies and scheduling them? Are
there grounds for refusing to participate?
Unprofessional, incompetent, unethical or illegal
doctor practice
A nurse who works in the operating room notices that a pae-
diatric surgeon who has been on the staff for several years
and done excellent work suddenly seems to be not concen-
trating during surgery and making more mistakes than usual.
Rumours have been circulating about the surgeon having a
problem with cocaine abuse after his recent divorce. The
parents of one paediatric patient are dissatisfied with the
Varcoe, C., Pauly B., Storch, J., Newton, L. & Makaroff, K.
(2012). Nurses’ perceptions of and responses to morally
distressing situations.
Nursing Ethics
, 19(4), 488–500.
This paper reports on a study of 292 nurses and endeav-
ours to understand the issue of moral distress in clinical
practice. The authors feel that stress associated with the
moral dimension of practice is now evident as nurses
become more aware of their role as moral agents.
Survey packages were distributed to nurses who
consented to participate in the study. The nurses’ per-
ceptions of the stress associated with moral distress and
ethical climate were surveyed using three open-ended
questions. Data were analysed drawing on interpretive
description, a qualitative research approach.
The analysis revealed that broad system factors
of work overload and staff incompetence led to the
inadequate care of patients. As well, specific situations
such as witnessing unnecessary suffering, moral com-
promises, and negative judgements about patients
and/or their families were recorded as contributing to
moral distress. The outcome suggested nurses require
a collective approach, to be able to action structural
changes instead of individual action.
Relevance to practice
This study revealed the concept of moral distress
requires further education so that all healthcare
workers can differentiate between moral distress and
personal value clashes. As well, the authors suggest
that, to facilitate collective action, education should
include political theory and analysis of moral distress
within power-laden contexts.
Moral distress and clash of personal value
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