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A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace

  • Monique Frances Crane (a1), Piers Bayl-Smith (a1) and John Cartmill (a2)


Despite the importance of moral distress in the nursing scholarship, little attention is paid to the phenomena in the psychological literature as an important occupational stressor. A factor limiting the application of moral distress to other occupational settings is its definitional features. First, a necessary condition of moral distress is the acknowledgment prior to behaviour initiation that behaviour will contravene personal moral ideals. Second, the definition of moral distress specifies that the inability to act in accordance with one's moral framework is driven by institutional constraints (non-autonomous behaviour). This article proposes that moral distress not be limited in these ways, and makes two central contributions to resolve this core problem. We offer a critique and extension of the conceptual definition of moral distress. Fourteen Australian medical doctors participated in a semi-structured interview regarding occupational morally distressing events. Medical doctors were chosen for our interviews because they are an occupational population with considerable decision-making autonomy. Based on the findings, two recommendations are made: (1) that the definition of moral distress is not limited to events where decision-making and behaviour is non-autonomous, and (2) moral distress should not be limited to occasions where the moral conflict is identified prior to decision-making or behaviour. An alternative definition of moral distress is proposed. We conclude that while organisational limitations are an important precipitate of moral distress, they are not a necessary condition for its emergence.


Corresponding author

address for correspondence: Monique Crane, Building C3A Department of Psychology, Macquarie University, Sydney NSW 2109, Australia. Email:


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Baldwin, P.J., Dodd, M., & Wrate, R. W. (1997). Young doctors’ health — I. How do working conditions affect attitudes, health and performance? Social Science & Medicine, 45, 3540.
Brehm, J.W., & Cohen, A.R. (1962). Explorations in cognitive dissonance. New York: Wiley.
Brooks, P.M., Lapsley, H.M., & Butt, D.B. (2003). Medical workforce issues in Australia: ‘Tomorrow's doctors – too few, too far’. Medical Journal of Australia, 179, 206208.
Corley, M.C., Elswick, R.K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33, 250256.
Corley, M.C., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12, 382390.
Elpern, E.H., Covert, B., & Kleinpell, R. (2005). Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care, (6), 523530.
Else-Quest, N.M., Higgins, A., Allison, C., & Morton, L.C. (2012). Gender differences in self-conscious emotional experience: A meta-analysis. Psychological Bulletin, 138, 947981.
Fahrenkopf, A.M., Sectish, T.C., Barger, L.K., Sharek, P.J., Lewin, D., Chiang, V.W., . . . Wiederman, B.L. (2008). Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ: Clinical Research Edition, 336, 488491.
Feskanick, J., Hastrup, J.L., Marshall, J.R., Colditz, G.A., Stampfer, M.J., Willett, W.C., & Kawachi, I. (2002). Stress and suicide in the nurses’ health Study. Journal of Epidemiology and Community Health, 56, 9598.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press.
Festinger, L., & Carlsmith, J.M. (1959). Cognitive consequences of forced compliance. Journal of Abnormal Psychology, 58, 203210.
Gallery, M.E., Whitley, T.W., Klonis, L.K., Anzinger, R.K., & Revicki, D.A. (1992). A study of occupational stress and depression among emergency physicians. Annuals of Emergency Medicine, 21, 5864.
Gray-Toft, P., & Anderson, J.G. (1981). Stress among hospital nursing staff: Its causes and effects. Social Science and Medicine-Part A Medical Sociology, 15, 639647.
Gutierrez, K.M. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24, 229241.
Hamric, A.B. (2012). Empirical research on moral distress: Issues, challenges, and opportunities. HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues, 24, 3949.
Hanna, D. (2004) Moral distress: The state of the science. Research and Theory in Nursing Practice, 18, 7393.
Healy, C.M., & McKay, M.F. (2000). Nursing stress: The effects of coping strategies and job satisfaction in a sample of Australian nurses. Journal of Advanced Nursing, 31, 681688.
Higgins, E.T. (1987). Self-discrepancy: A theory relating self and affect. Psychological Review, 94, 319–40.
Higgins, E.T., & Bargh, J.A. (1987). Social cognition and social perception. Annual Review of Psychology, 38, 369425.
Higgins, E.T., Bond, R.N., Klein, R., & Strauman, T. (1986). Self-discrepancies and emotional vulnerability: how magnitude, accessibility, and type of discrepancy influence affect. Journal of Personality and Social Psychology, 51, 515.
Higgins, E.T., Klein, R., & Strauman, T. (1985). Self-concept discrepancy theory: A psychological model for distinguishing among different aspects of depression and anxiety. Social Cognition, 3, 5176.
Hsu, K., & Marshall, V. (1987). Prevalence of depression and distress in a large sample of Canadian residents, interns, and fellows. American Journal of Psychiatry, 144, 15611566.
Jackall, R. (1988). Moral mazes: The world of corporate managers. New York: Oxford University Press.
Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.
Jex, S.M., Hughes, P., Storr, C., Baldwin, D.C., Conard, S., & Sheehan, D.V. (1991). Behavioral consequences of job related stress among resident physicians: The mediating role of psychological strain. Psychological Reports, 69, 339349.
Kälvemark, S., Höglund, A.T., Hansson, M.G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts-ethical dilemmas and moral distress in the health care system. Social Science & Medicine, 58 (6), 10751084.
Kleppa, E., Sanne, B., & Tell, G.S. (2008). Working overtime is associated with anxiety and depression: The Hordaland Health Study. Journal of Occupational and Environmental Medicine, 50, 658666.
Lglesias, E., Vallejo, R.B.B., & Fuentes, P.S. (2010). Moral distress related to ethical dilemmas among Spanish podiatrists. Journal of Medical Ethics, 36, 310314.
Lindeman, S., Laara, E., Hakko, H., & Lonnqvist, J. (1996). A systematic review on gender-specific suicide mortality in medical doctors. The British Journal of Psychiatry, 168 (3), 274279.
Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695706.
Lützén, K., Cronqvist, A., Magnusson, A., & Andersson, L. (2003). Moral stress: Synthesis of a concept. Nursing Ethics, 10, 312322.
Lützén, K., & Kvist, B.E. (2012). Moral distress: A comparative analysis of theoretical understandings and inter-related concepts. HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues, 24, 1325.
Ohnishi, K., Ohgushi, Y., Nakano, M., Fujii, H., Tanaka, H., Kitaoka, K., . . . Narita, Y. (2010). Moral distress experienced by psychiatric nurses in Japan. Nursing Ethics, 17, 726740.
Opie, T., Dollard, M., Lenthall, S., Wakerman, J., Dunn, S., Knight, S., & MacLeod, M. (2010). Levels of occupational stress in the remote area nursing workforce. Australian Journal of Rural Health, 18, 235241.
Price, J., Tangney, J.P., Stuewig, J., & Mashek, D.J. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345372.
Pitt, E., Rosenthal, M., Gay, T.L., & Lewton, E. (2004). Mental health services for residents: More important than ever. Academic Medicine, 79, 840844.
Rice, E.M., Rady, M.Y., Hamrick, A., Verheijde, J.L., & Pendergast, D.K. (2008). Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management, 16, 360373.
Severinsson, E. (2003). Moral stress and burnout: Qualitative content analysis. Nursing and Health Sciences, 5, 5966.
Shanafelt, T.D., Bradley, K.A., Wipf, J.E., & Back, A.L. (2002). Burnout and self-reported patient care in an internal medicine residency program. Annuals of Internal Medicine, 136, 358367.
Simon, H.A. (1996). Models of my life. Cambridge, MA: MIT Press
Simon, H.A. (1999). The potlatch between political science and economics. In Alt, J.E., Levi, M., & Ostrom, E. (Eds.), Competition and cooperation: Conversations with Nobelists about economics and political science (pp. 112119). Cambridge, UK: Cambridge University Press.
Sporrong, S.K., Hoglund, A.T., & Arnetz, B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13, 416427.
Sundin-Huard, D., & Fahy, K. (1999). Moral distress, advocacy and burnout: Theorising the relationships. International Journal of Nursing Practice, 5, 813.
Tomioka, K., Morita, N., Saeki, K., Okamoto, N., & Kurumatani, N. (2011). Working hours, occupational stress and depression among physicians. Occupational Medicine, 61,163170.
Tyler, P., & Cushway, D. (1998). Stress and well-being in health-care staff: The role of negative affectivity, and perceptions of job demand and discretion. Stress Medicine, 14, 99107.
Weinstein, N.D. (1989) Optimistic biases about personal risks. Science, 246, 12321233.
Wicklund, R.A., & Brehm, J.W. (1976). Perspectives on cognitive dissonance. Oxford, UK: Lawrence Erlbaum.
Wilkinson, J.M. (1987/1988) Moral distress in nursing practice: Experience and effect. Nursing Forum, 23, 1629.
Zuzelo, P.R. (2007). Exploring moral distress in registered nurses. Nursing Ethics, 14, 344359.


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A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace

  • Monique Frances Crane (a1), Piers Bayl-Smith (a1) and John Cartmill (a2)


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