Moral Distress Reexamined: A Feminist Interpretation of Nurses Identities, Relationships, and Responsibilites

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1 Bioethical Inquiry (2013) 10: DOI /s SYMPOSIUM Moral Distress Reexamined: A Feminist Interpretation of Nurses Identities, Relationships, and Responsibilites Elizabeth Peter & Joan Liaschenko Received: 10 September 2012 /Accepted: 22 May 2013 /Published online: 11 June 2013 # Springer Science+Business Media Dordrecht 2013 Abstract Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and responsibilities in situations of moral distress. We also discuss the importance of nurses creating counterstories of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward E. Peter (*) Lawrence S. Bloomberg Faculty of Nursing Member, Joint Centre for Bioethics, University of Toronto, Suite College St., Toronto, ON M5T 1P8, Canada elizabeth.peter@utoronto.ca J. Liaschenko Center for Bioethics and School of Nursing, University of Minnesota, N504 Boynton 410 Church Street SE, Minneapolis, MN , USA jliasch@umn.edu shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. Keywords Moral distress. Nursing. Feminist ethics. End-of-life The concept of moral distress has been highly prevalent in the nursing literature since its inception in 1984 by philosopher Andrew Jameton. He defined moral distress as arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action (Jameton 1984, 6). Since that time, several definitions have arisen (Wilkinson 1987; Kälvemark et al. 2004) and many research studies on moral distress have been conducted (Huffman and Rittenmeyer 2012), along with considerable attention to the need for greater conceptual clarity (McCarthy and Deady 2008; Pauly, Varcoe, and Storch 2012; Varcoe et al. 2012a). Suggestions have been made that the attention be turned away from developing consensus on a definition to the development of conceptual models (Lützen and Kvist 2012), especially ones that explicate the relationships among various concepts (Varcoe et al. 2012a). Similarly, McCarthy and Deady (2008) call for philosophical perspectives to be used in the reconsideration of this concept.

2 338 Bioethical Inquiry (2013) 10: In this paper, we begin to theorize moral distress using feminist moral theory, particularly that of Margaret Urban Walker and Hilde Lindemann. In doing so, we are offering one perspective among many possible ones that could be generated using a variety of philosophical approaches. We focus on theorizing the moral distress of hospital nurses, because the preponderance of empirical evidence has described their experiences of moral distress and because this paper is only an initial attempt. There is no doubt, however, that nurses in the community and other health care professionals experience moral distress (Kälvemark et al. 2004; Brazil et al. 2010; Piers et al. 2011). In our conversations while writing this paper we struggled ourselves with which of our experiences and those of others could be properly labeled as moral distress, ultimately agreeing with McCarthy and Deady that moral distress is an umbrella concept that captures the range of experiences of individuals who are morally constrained (2008, 254). While the existing literature acknowledges both the individual and institutional components of moral distress, little of this scholarship has taken us much beyond that to offer a deeper theoretical explanation of how these components are related. We propose that an understanding of moral distress within the context of feminist moral theory offers a richer explanation of what is morally at stake when moral distress is experienced because it can capture three core elements of moral agency: identities, relationships, and responsibilities. These elements rest on a conception of moral agency as socially connected, implying that people s ability to identify, deliberate, and act on moral phenomena occurs in a relational context (Peter 2011; Young 2006, 2011). As such, our identities, responsibilities, and relationships within communities are central to morality. We begin by providing a brief outline of feminist moral theory, concentrating on the work of Walker and Lindemann, and then examine, using empirical evidence, how moral distress can be conceptualized as a reaction to the constraints to the moral identities, responsibilities, and relationships of nurses. In doing so, we offer a comprehensive understanding of the current nature and contexts of nursing work such that possible changes to this work can be identified to diminish moral distress. Finally, using the insights that a more developed theorization of moral distress offers, we suggest three bottom-up approaches to diminish moral distress, which we hope are, in the end, helpful in making institutional structures more morally habitable. First we make recommendations, based on a framework created by Verkerk and Lindemann (2009), to assist health professionals to account for and communicate their values and responsibilities in situations of moral distress involving nurses and other health care professionals. This process has the potential to lead to more transparent and mutually intelligible relationships in the long-term. Second, we discuss the importance of nurses creating counterstories of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities and to help lessen the occurrence of moral distress. Third, given the high relationship between the experience of moral distress and aggressive care at end-of-life, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering be made by health care professionals working together. Feminist Ethics and Health Care Ethics Approaches in feminist ethics share a number of common features that can inform the recognition of the work life elements that lead to moral distress in nursing in such a way that a more robust theorization of moral distress can be developed. Feminist ethics, as an emancipatory approach, is committed to changing uneven distributions of power and privilege in everyday life, resulting in a blurry boundary between ethics and politics (Liaschenko and Peter 2006). Feminists examine more than gender differences that result in power imbalances, but also include factors such as race, class, socioeconomic status, and ability. Drawing from the work of care ethicists such as Gilligan (1982), Held (1993), and Tronto (1994), persons are interdependent, connected to others, and vulnerable from this viewpoint. Feminists also espouse a naturalized moral epistemology, meaning that moral knowledge comes from and is revised through moral experience (Lindemann 2006), particularly our shared experiences of identifying and meeting our everyday responsibilities. Margaret Urban Walker argues that morality at its core is the socially embodied medium of mutual understandings and negotiation between people over their responsibility for things open to human care

3 Bioethical Inquiry (2013) 10: and response (1998, 9). Through our shared understandings and negotiations with others we determine the scope of our agency, affirm our identities and values, and make ourselves accountable to each other (Walker 1998). These understandings and responsibilities, however, need to be examined critically to ensure that they really are acceptable and coherent to those who hold them. Critical reflection tests whether moral understandings really are intelligible and coherent to those who enact them. Do these practices engender cooperation, the shared benefit of societal goods, and mutual recognition, or do they produce oppression and suffering? This type of testing that makes transparent the relationships and practices of responsibility reveals to what extent a given community is morally habitable (Walker 1998). Feminist health care ethics is especially useful in exploring nursing issues and uncovering nursing knowledge because the work of nurses is deeply embedded in complex social networks involving health care professionals, patients, families, and administrators, all of whom are further nested in politics, policies, and economics. The often hierarchical nature of teams and the vulnerability of many patients make an approach that directly addresses power differences very helpful. The capacity to capture the political or structural dimensions of moral distress through a theoretical approach has been identified as important in further research examining moral distress (Pauly, Varcoe, and Storch 2012; Varcoe et al. 2012a). It is also useful in exploring whether the underlying moral understandings of nurses and others are fostering morally habitable workplaces. This paper itself can be viewed as a form of critical transparency testing because moral distress could be a strong indication of morally uninhabitable workplaces in which incoherent understandings and unsustainable practices exist. We believe that moral distress is fundamentally a reaction to the constraints to the moral identities, relationships, and responsibilities of nurses that underlie these understandings and practices. Moral Identities Feminist ethical theory does not subscribe to universal moral truths that transcend time and place. Rather, morality is bound to specific historical times and places. Morality is not a type of formal knowledge that guides action but is a set of socially embodied practices. Morality is not transcendental, that is, it is not grounded in a supernatural being or some pure, abstract notion of reason. Morality is a social accomplishment that happens between people as they account to each other and to themselves for that which they are responsible. People account for what they see as morally relevant and for whom they take themselves to be (Walker 1998, 2009). Moral agents are not disembodied rational agents in feminist ethics but embodied beings whose identities are shaped by the historical circumstances of their lives and the master narratives of those periods that set boundaries on who can be what kind of person and why. As such, identities are key in feminist ethics. Specifically, Walker (1998) describes moral identity as an ongoing history of what a person takes responsibility for, responds to, is concerned about, cares for, and values. We review our moral histories to clarify our values and ongoing commitments to create an awareness of ourselves as we have acted in the past and to direct future courses of action. Identities have complex features that can show themselves in narratives and are important to consider when examining moral practices. These identities are socially constructed, multiple, relational, and often unchosen and are relevant to ethics because they set up expectations on people (Nelson 2001; Lindemann 2006). Identities are described as socially constructed because they are created by the practices and institutions characteristic of a particular way of living (Lindemann 2006). The identity of nurse is a social construction. It is generally associated with being a woman, a kind caregiver, an assistant to the physician, and a virtuous healer. These constructions might not reflect the work, gender, or character of many nurses. Yet, this nurse identity is something nurses encounter and perhaps embrace as they begin their education and work. Nurses participate in this construction by the roles they assume and how they describe themselves. Some have argued that aspects of this construction are destructive to the identities of nurses. For example, Gordon and Nelson (2005) have argued that the virtue script of nurses that is, the overemphasis on the social construction of nurses as virtuous, angelic caregivers in the health care system is destructive to the identity of nurses as knowledgeable and skilled professionals. Lindemann (2006) would describe this script as a master narrative that represents the identity

4 340 Bioethical Inquiry (2013) 10: of a group of people in a certain way that is unconsciously absorbed by the group. The narrative then becomes prescriptive, directing the values and practices of the group. In the case of nurses we believe it is not that virtue as a narrative is itself a problem for the moral identity of nurses, but instead it is the assumption that the virtuous actions of nurses do not require knowledge and skill that is a problem. A recent systematic review by Huffman and Rittenmeyer (2012) that critically examined 39 qualitative studies published from 1995 to 2008 of the moral distress of nurses working in hospital environments is very helpful in exploring how moral identity is related to moral distress. They report on the moral distress that nurses experience when they cannot enact their core values, especially the value of holistic care. Poor staffing and increased workload decrease the opportunity for nurses to develop interpersonal relationships with patients, which is a great source of frustration for nurses leading to moral distress (Huffman and Rittenmeyer 2012). This finding is to be expected given the high value nurses place on the nurse patient relationship and patient advocacy. A well-known study by Kelly (1998) explored how new graduates of nursing adapt to hospital nursing and what they perceive to be key influences in their values and roles. These neophyte nurses experience moral distress as they struggle to preserve their moral integrity. Moral distress is felt most intensely when they realize that they can never reach their ideals of patient care that are central to their moral identities as nurses. The discrepancy between what they learn in school and the realities of practice are too great to adapt to easily. Kelly (1998) suggests that nurses are often unprepared to work well as members of a team, perhaps because individual performance is overly emphasized in education. Greater awareness of the roles and values of other team members and the significance of their own their own roles might help nurses to better cope with differences in moral understandings as they negotiate their responsibilities in their everyday work. Relationships Morality is a part of human life that consists of relationships based on trust in which we possess and negotiate mutual expectations and call on each other to account for things we do and fail to do. In this way, we rely on others to be responsive to these normative expectations. For moral relationships to be sustained we need confidence that some shared standards exist that will lead to human flourishing and we trust that others will adhere to these standards. It must be noted that some members of a community might not fully comprehend the standards in the same way, given that we are not situated uniformly, resulting in breakdowns in relationships. These breakdowns ideally can form the opportunity for reconciliation and the rethinking of expectations when needed (Walker 1998). Moral relationships have shared and individual histories. We possess histories of expectations and responsibilities, types of trust, and the potential for future continuation within a relationship or within a web of relationships. We may struggle with what responsibilities we have to others given our history with them and the nature of the commitment that it has created. For example, we may care for a sick friend or relative despite its demands on us because of the deep concern and commitment we have to this person. Our understanding of this relationship and the responsibilities it holds are understood to us in narrative form as we come to reflect and act on responsibilities in relationships. At times, even with a very limited history of relationship to another person, we may respond in times of urgent need or when no one is else is available (Walker 1998). Nurses and other health care professionals, because of their professional socialization, understand these relationships of care in terms of larger narratives that inform their work. Standards of practice, ideals surrounding nurse patient relationships, codes of ethics along with stories of clinical relationships to patients tell nurses how to respond to patients, even without a lengthy relationship history. Walker informs us, however, that moral relationships also require distinctive forms of response resentment and indignation that register violations of shared understandings, demand accountability, and prompt corrections of unacceptable behaviour (2006, 24). In other words, when normative expectations are not met we respond emotionally to this failure and, while Walker (1998) does not use the term moral distress, the terms resentment and indignation are consistent with the reactions of anger, frustration, guilt, and anxiety that nurses with moral distress experience (Huffman and Rittenmeyer 2012; Varcoe et al. 2012b). Using Walker s (1998) perspective, relationships of trust in health care are built on the

5 Bioethical Inquiry (2013) 10: presumption that there are shared understandings and normative expectations that all relevant parties which would include nurses, physicians, other allied health care professionals, patients, administrators, and policy-makers should have based on similar values that would dictate what kinds of actions are appropriate in a given circumstance. Moral distress may be the reaction to the recognition that others cannot be trusted. Baier speaks of judging what should count as failing to meet trust, either through incompetence, negligence, or ill will (1986, 238). In this instance, these factors lead to the failure to adhere to normative expectations that heretofore were believed to be shared. For example, moral distress is often the result of problems in the nurse physician relationship. Nurses lower place in the hierarchy relative to physicians is thought to be underlying many of these problems, notably when nurses believe they have little influence over treatment decisions with which they disagree and when they believe their expertise is devalued. These conflicts often become most evident when nurses and physicians have opposing perspectives of what the best care and treatment for patients should be (Huffman and Rittenmeyer 2012). Nurses are often socialized today to believe that they are respected members of the health care team that is dedicated to holistic patient-centered care. To experience the devaluation of their perspectives in environments that seem not to value the holistic needs of patients is to experience a fundamental violation of trust and a constraint to moral agency. In turn, it is to no surprise, nurses experience moral distress. Other sources of moral distress include nurses belief that institutions are primarily focusing on costcontainment and efficiency. The resulting financial constraints and staffing cuts result in the inability to provide high-quality nursing care and ultimately to nurses acute moral distress (Huffman and Rittenmeyer 2012; Varcoe et al. 2012a, b). Here again we see how normative expectations can differ in relationships, but in this case the relationship under consideration is nurses relationships to institutions. Huffman and Rittenmeyer speak of institutional culpability (2012, 96) when describing the role of institutions in creating the conditions for moral distress. Without the support of institutions, nurses cannot fulfill their professional responsibilities, revealing the connected nature of moral agency and the vulnerability all health care professionals have within complex networks of care delivery. The moral distress experienced by nurses in these instances is again a reaction to a violation of trust and constraints to moral agency because of nurses anticipation that the institutions in which they work will place quality of care above other values, such as efficiency. Responsibilities Responsibilities are determined through histories of trust, expectation, and agreement that make particular relationships morally demanding in particular ways (Walker 1998, 69). With respect to nurses and other health care professionals, specific responsibilities to patients, the team, and society as a whole are the result of lengthy histories of custom and regulation that have formed and perpetuated these expectations. These are enshrined in standards of practice and codes of ethics and are inculcated through professional socialization. For example, the International Council of Nurses Code of Ethics for Nurses clearly articulates nurses responsibilities, stating: Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering (2006, 1). Like other health care professionals, however, how these responsibilities are realized is dependent on other team members recognizing and supporting these responsibilities. Because few responsibilities in the delivery of health care are truly independent, responsibilities need to be continually negotiated and made transparent to avoid misunderstandings. Nurses responsibilities place them in the same time-space as their patients (Cohen 2011), meaning that they are often the one professional group that remains continually at the bedside of patients. The nature of the needs of hospitalized patients is such that caregivers must be promptly available, making it necessary for nurses to remain near to the bedside. Close proximity to patients who suffer unnecessarily can heighten moral distress, because it tends to elicit an emotionally laden caring response that might not be present when more distance is allowed (Peter and Liaschenko 2004). Witnessing end-of-life care that is perceived to be overly aggressive is an especially common source of moral distress in nurses (Huffman and Rittenmeyer 2012; Varcoe et al. 2012b). Responsibility to relieve suffering is so core to the nurses values and identity that moral distress in response to

6 342 Bioethical Inquiry (2013) 10: the lengthy exposure to patient suffering is to be anticipated. Because nurses are also responsible for carrying out the orders of physicians, albeit not in an unquestioning manner, they are also responsible for enacting orders with which they might not agree, such as those for aggressive care at end-of-life. While conscientious objection is widely accepted in cases of disagreement with participation in therapeutic abortion, it is not a commonly accepted practice with respect to other issues. Consequently, nurses responsibilities can extend not only to witnessing suffering but also to the requirement to provide treatments that they believe create suffering. Recommendations In the end, the most important reason to bring conceptual clarity to the phenomenon of moral distress is to diminish its prevalence in practice. The goal, however, is not to create practitioners who are morally oblivious and not aware of the moral demands being placed on them (DesAutels 2004), because moral distress alerts us that something of great significance is being threatened or constrained, namely our moral identities, responsibilities, and relationships. Instead, we propose strategies that may help build conditions in institutions that lessen the likelihood that these constraints and threats will arise, recognizing that these conditions are not easily changed. At the very least, we believe that our suggestions could minimally lead to a rethinking of the issues. Accounting For and Communicating Values and Responsibilities Since morality is interpersonal and collaborative, we offer suggestions based on the work of Verkerk and Lindemann (2009) that targets how moral agents experiencing moral distress can account for who they are as professionals and demand an accounting from others. Such an accounting requires that moral agents make explicit and morally intelligible to others what values they hold, the multiple origins of these values, the cultural norms influencing these values, the responsibilities that flow from these understandings, the consequences of any action taken in response to these responsibilities, and how these understandings are taken up or shared (or not shared) in the networks of relationships in which the particular moral agent is embedded. If moral distress can be the result of the recognition that moral understandings and expectations are not shared, then the remedy for moral distress must lie in making explicit moral understandings and expectations for action to the relevant moral actors so that expectations can potentially be fulfilled. Making explicit or accounting for what moral agents see as important and respond to is a social process that focuses on the relationship between our intentions and actions and the ends of our actions. It makes us ask and answer: What are we doing? It is an evaluative process that submits our values, beliefs, and actions to the moral evaluation of others. Moral distress, therefore, can be a mobilizer for asking questions, opening dialogue, and self-reflection for the health care team, and not just the source of suffering (Lunardi et al. 2009). It opens critical spaces so that the moral habitability of a given environment can be evaluated from the perspective of differently situated people. Morally habitable social arrangements are those that cultivate recognition, cooperation, and the sharing of social goods as opposed to oppression, deprivation, and suffering (Walker 1998). For example, nurses on a hospital unit are distressed over what they consider to be the lack of opportunity due to understaffing and pressure to discharge patients rapidly to form meaningful relationships with their patients and their families so that comprehensive discharge plans can be made. In the same situation, the administrators, who are working under budget restraints, believe that efficiency and the prudent allocation of resources are important to ensure the widest distribution of resources possible and have reduced the number of nurses to meet the bottom line, and the physicians in the emergency room of the same hospital are very concerned when they cannot admit patients to the unit quickly and patients are left waiting for extended periods of time on stretchers. The moral identities and responsibilities of all players could be damaged if they cannot enact their values to provide good care to patients, and the relationships among them are also likely to suffer if blaming and conflict among them arise. The likelihood of this type of situation, therefore, of resulting in the moral distress of all involved is high. Verkerk and Lindemann (2009) suggest that bioethicists can be helpful in supporting professionals to

7 Bioethical Inquiry (2013) 10: enhance their moral sensitivity in ethically difficult situations by assisting them to identify and articulate their own values and responsibilities in their work. These responsibilities can then be mapped onto a geography of responsibility (Walker 1998) so that transparency can be created to ascertain how accountability for various arrangements and tasks is assigned and how they are to be enacted (Verkerk and Lindemann 2009). In the above example, it evident what some of the core values and beliefs are of these professionals, but in actual practice these may not be so readily apparent. These professionals may need time and assistance to recognize why they are distressed and what is informing their actions. While all have the responsibility to ensure excellent patient care, they rely on different knowledge, expertise, and values because their specific responsibilities are differentiated. Health professionals are also situated variably within the social hierarchy of hospitals. In the example, the nurses, while not powerless, are most likely the group with the least formal power. A bioethicist needs to ensure that no one is dismissed as not having a legitimate stake in this situation such that their concerns are not acknowledged. Repairing Damaged Moral Identities: The Creation of Counterstories Because identities are created narratively, they can be repaired narratively as well (Lindemann 2006). One source of moral distress is the result of the damage to nurses moral identity as holistic care providers in circumstances in which their values are not supported by others in their institutions or the knowledge they possess is not recognized. Nelson (2001) describes the importance of creating counterstories to repair damaged identities and challenge dominant narratives. She describes the oppressive identity of nurses as consisting of overly touchy-feely portrayals of nurses that suggest stereotypes of women s inferiority. With these narratives, nurses are viewed as being capable of emotion, but not reason, and being able to be like mothers, but not of being scientific. Nurses, themselves, and others need to see nurses as morally and epistemically trustworthy for the repair of their moral identities to occur. Counterstories are needed that portray nurses as skilled caregivers with serious responsibilities that require knowledge, skill, and virtue. These also have the potential to portray nurses as powerful. It is also important for nurses to create counterstories that can act as forms of resistance that place significance on nurses power as opposed to their vulnerability. Mc- Carthy and Deady (2008) raise concerns that an overemphasis upon nurses moral distress is damaging to nurses, because it implies that nurses have little power to do anything about their distress or the situations that create it. They worry that moral distress could become the dominant narrative in understanding the impact of moral decision-making on the professional identity of nurses. Ironically, therefore, too much attention given to moral distress could result in more moral distress because its emphasis upon powerlessness could be identity-damaging. In fact, a manuscript such as this one also runs the danger of perpetuating the problem without adequate attention to the power nurses possess to make changes. A deeper theorization of moral distress, however, makes it possible to strategize how nurses power can best be used to combat this problem. The place of nurses work between patients, other health care providers, and the institution not only can constrain their agency, it can often place them in a position to exercise connective power in ways that might not always be fully recognized. They possess the social knowledge and power of how to accomplish things in health care institutions, including moving patients through the system, connecting them to resources, and coordinating many aspects of care (Liaschenko and Fisher 1999). The knowledge that nurses have in this regard, along with more conventional types of biomedical knowledge, needs to be better communicated so that counter-narratives can be constructed to challenge the perception of nurses powerlessness and lack of expertise. Moving Toward the Relief of Human Suffering The social knowledge and power of nurses can also be used by nurses to connect with other health care professionals to bring about change to diminish moral distress. Nurses are not the only group to experience moral distress. Other health care professionals experience moral distress as well, particularly in response to overly aggressive care at end-of-life (Hamric and Blackhall 2007; Piers et al. 2011) which, as discussed earlier, is consistent with the experience of nurses

8 344 Bioethical Inquiry (2013) 10: (Huffman and Rittenmeyer 2012; Varcoe et al. 2012b). Van Heijst (2009) maintains that the paradigm that has dominated Western institutional health care since the end of the 19th century has cure and the prolongation of life as its aim. While death is often postponed, quality of life may be compromised. van Heijst asks, Do treatments of this kind suit the patients own good, or are they forms of sophisticated cruelty (2009, 201)? Since the values of altruism and compassion underlie the identities, relationships, and responsibilities of all health care professionals, it is not surprising that they experience moral distress when the care they provide is perceived to be sophisticated cruelty. Van Heijst advocates for a paradigm shift in which the goal of health care would be the relief of patient suffering, recognizing that this will only occur if on a cultural and symbolic level, we succeed in making friends with the human conditions of transience and mortality (2009, 200). Nurses are in a good position to bring others together to begin to create this kind of change in paradigm through dialogue and modifications in practice. No doubt, this kind of change will require vast transformations in society s desire for life prolongation. Recent work focusing on the education of future health care professionals and ethicists underscores the relevance of professionals working together, as opposed to working in silos, to adjust their focus beyond the medical model to that of health equity and social justice (Frenk et al. 2010; Peter 2011; Sherwin 2011). This kind of focus is in keeping with a paradigm that is not primarily about postponing death but is, instead, about relieving suffering in a variety of ways. Conclusions Moral distress is a complex phenomenon that can be conceptualized and theorized in a variety of ways. We chose to use feminist ethics to add theoretical depth to this concept. Research findings support the notion that moral distress can be interpreted as a response to constraints, or threatened constraints, to the moral identities, relationships, and responsibilities of nurses and other health professionals. We hope that others will build on our work and discover whether our recommendations that involve (1) health professionals learning to better account for and communicate their values and responsibilities, (2) the creation of counterstories of nurses as skillful and trustworthy to repair their damaged moral identities, and (3) the movement toward the relief of human suffering as the goal of health care as opposed to the prolongation of life at all costs are helpful. We recognize that these will require vast changes in attitudes and beliefs but without strategies for change moral distress is likely to increase in prevalence as resources diminish and the push for new life-saving technologies continues. For almost 30 years moral distress has been described in numerous studies. In the future, the attention should turn to finding ways of better understanding moral distress so that the conditions that further it can be altered. References Baier, A Trust and antitrust. Ethics 96(2): Brazil, K., S. Kassalainen, J. Ploeg, and D. Marshall Moral distress experienced by health care professionals who provide home-based palliative care. Social Science & Medicine 71(9): Cohen, R.L Time, space and touch at work: Body work and labour process (re)organisation. Sociology of Health & Illness 33(2): DesAutels, P Moral mindfulness. In Moral psychology: Feminist ethics and social theory, ed. P. DesAutels and M.U. Walker, Lanham: Rowman and Littlefield Publishers Inc. Frenk, J., L. Chen, A.B. Zulfiquar, et al Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet 376(9756): Gilligan, C In a different voice: Psychological theory and women s development. Cambridge: Harvard University Press. Gordon, S., and S. Nelson An end to angels. The American Journal of Nursing 105(5): Hamric, D.M., and L.J. Blackhall Nurse physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35(2): Held, V Feminist morality: Transforming culture, society, and politics. Chicago: University of Chicago Press. Huffman, D.M., and L. Rittenmeyer How professional nurses working in hospital environments experience moral distress: A systematic review. Critical Care Nursing Clinics of North America 24(1): International Council of Nurses The ICN code of ethics for nurses. Geneva: International Council of Nurses. Jameton, A Nursing practice: The ethical issues. Englewood Cliffs: Prentice-Hall. Kälvemark, S., A.T. Höglund, M.G. Hansson, P. Westerholm, and B. Arnetz Living with conflicts-ethical dilemmas

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