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Running head: MORAL DISTRESS AND PALLIATIVE CARE 1
Nurses’ Moral Distress and the Role of Palliative Care: A Systematic Review
MORAL DISTRESS AND PALLIATIVE CARE 2
Abstract
Moral distress has been a topic in nursing literature for over 20 years. Researchers have
documented its conceptual meaning, presentation, and impact through qualitative and
quantitative methods as well as reviews. Recently, efforts have been made to determine the
effectiveness of various interventions on moral distress. One of these is these is the role of
palliative and end of life care education. The purpose of this review was to describe how
palliative and end of life care impacts moral distress scores in nursing professionals. The
research design was a systematic review which produced three articles published between 1987
and 2018 which matched the search criteria. Through the PRISMA reporting guidelines, the
findings are presented in a narrative synthesis. From the analysis, it emerged that the
heterogeneity among variables, measurement and definition of moral distress, and selection bias
and confounding variables impacted the interpretation of the included studies. Few studies
examine how palliative care and end of life care education impacted nursing moral distress.
Furthermore, determining conceptual validity of the measurements used is encouraged.
Nurses’ Moral Distress and the Role of Palliative Care: A Systematic Review
MORAL DISTRESS AND PALLIATIVE CARE 3
Moral distress is an important issue as it pertains to healthcare professionals due to its
negative impact on the professional’s mental and emotional wellbeing, turnover, and patient care
(Hamric, 2012). Although moral distress can occur in personal and professional settings, the
focus on nurses’ moral distress emerged with the rise of feminist ethics in the 1970s (Jameton,
2013). At that time, most medical ethical dilemmas focused on the role of the male physician
which reflected hospital paternal bureaucratic structures. Philosophers sought to support the
female dominated nursing profession and encourage their confidence and voice. Since then,
moral distress research has expanded and is encouraged in the fields of social work, medical
students, education, and others (Bradbury-Jones, Ives, Irvine, & Morley, 2017). Although the
causes of nursing moral distress are well understood, interventional outcomes remain under-
researched (Hamric, 2012).
Moral distress is a unique concept concerned with the psychological reaction to a moral
event (Morley et al., 2017). With over 20 definitions of what constitutes moral distress, there is
no consensus on how moral distress is defined. Jameton (1984) introduced moral distress as the
experience of negative feelings when a course of action is blocked by institution constraints.
Wilkinson, Corley, Hanna, and others have elaborated and supplemented their own notions of
what constitutes moral distress (Mareš, 2016; Morley et al., 2017). However, for the purposes of
this research, moral distress will be defined consistent with Jameton’s definition with Corley
(2002) and Borchers, Epstein, and Hamric (2012) interpretation: the response a nurse gives to a
moral situation where the nurse feels a sense of responsibility and their core beliefs or values
have been violated due to internal and/or external constraints. Internal constraints can be
perceived powerlessness or incompetency, whereas external constraints can be inflicted by the
MORAL DISTRESS AND PALLIATIVE CARE 4
institution or culture, such as lack of administrative support or having adequate time to complete
tasks and meet patient needs (Hamric, Davis, & Childress, 2006).
A variety of measurement tools have been developed in part due to the lack of
conceptualization consensus (Borchers, Epstein, & Hamric, 2012). Recent comprehensive and
systematic reviews have reported root causes and consequences of moral distress, but
methodologies included a variety of instruments that capture the phenomenon (Lamiani, Borghi,
& Argentero, 2017; McAndrew, Leske, & Schroeter, 2016; Wocial & Weaver, 2013; Younjae &
Gastmans, 2013). One of the earliest measurements of responses to moral dilemmas was
administered by Crisham (1981) to gauge nurses’ responses to ethical dilemmas. The Nursing
Dilemma Test (NDT) had poor reliability and lead to the creation of the Moral Distress Scale
(MDS) in 2001 (Corley, Elswick, Gorman, & Clor, 2001; Corley & Selig, 1994). In 2005, Corley
and colleagues revised their original scale to include six additional items from new literature and
dichotomized options to include frequency and intensity (MDS-A). Hamric, Borchers, and
Epstein (2012) conducted another revision to the scale (MDS-R) and expanded it to include other
health care professionals. The new scale is 21 items with 5-point Likert scale to reflect frequency
and intensity (α= .88). Each of the revisions of the MDS is based on research findings to reflect
the most current causes associated with moral distress. In 2013, Wocial and Weaver developed
the moral distress thermometer. This tool allows for moral distress to be measured in its current
state (rather than cumulative) with an eleven-point analogue scale. Other studies have used
unique questionnaires and some unidimensional measurements (Rathert, May, & Chung, 2016).
Through qualitative and quantitative measures, existing literature demonstrates
contributing sources of moral distress from patient and family, unit and team, and system and
organizational levels (Hamric, Whitehead, Prompahakul, & Esptein, 2018). Organizational
MORAL DISTRESS AND PALLIATIVE CARE 5
factors such as lack of support, respect, ethical debate, collaboration, access to resources and
adequate staffing (Hamric et al., 2012; Lamiani et al., 2017; Nathaniel, 2006). Although these
issues can be problematic for all healthcare professionals, these constraints create difficult
working environments for nurses. Nurses are often seen as advocates for patients but have a
limited role in controlling the treatment plan. Whether a nurse receives adequate support from
his or her administration can be crucial. In fact, studies have examined the relationship between
ethical workplaces and moral distress and consistently find a negatively correlated relationship
(Pauly, Varcoe, Storch, & Newton, 2009).
Whether a situation is considered morally distressing is a matter of individual nurse
perception. Nurses who feel they are forced to make decisions which conflict with professional
and/or institutional norms contributes to moral distress (Nathaniel, 2006). The constraints may be
real, but whether a nurse considers something to be morally distressing depends on the nurse.
The perception of powerlessness and ethical issues can amplify moral distress which reflects the
web of interactions among lack of organizational support, ethical environments, and individual
nurse contributions (Huffman & Rittenmeyer, 2009; Rathert et al., 2016).
Nurses report infrequent situations of moral distress, but when moral distress occurs,
nurses report intense levels (McAndrew et al., 2016; Younjae & Gastmans, 2013). Situations
where patient autonomy is disregarded, perceived pain and suffering, futile care, and lack of
informed consent and truth telling (honesty with patients about their medical condition) can be
sources of moral distress (Gillon, 1985; Hamric et al., 2012; Huffman & Rittenmeyer, 2009).
If left unaddressed, moral distress can create consequences for the nurses emotional and
psychological wellbeing, the institution, and patient-care. As a result of moral distress, nurses
have reported negative psychological, biological, and stress reactions (Huffman & Rittenmeyer,
MORAL DISTRESS AND PALLIATIVE CARE 6
2009). Over time, unresolved moral distress builds up and this moral residue contributes to the
intensifying of situations which feel familiar (Epstein & Hamric, 2009). In the presence of
internal constraints, often nurses will blame themselves but resort to blaming others when
dealing with external constraints (Dudzinski, 2016). These realities contribute to burnout, impair
work satisfaction, and turnover (Hamric et al., 2006; Rosenstein, 2002; Whitehead et al., 2015).
Leske, McAndrew, & Schroeter (2016) identified multiple studies which found moral distress
can contribute to nurses becoming desensitized, withdraw from patient care, and avoid patients
and families. This can have implications for the quality of care patients and families may receive.
A common source of moral distress is around perceived futile care and end of life care
(Hamric & Blackhall, 2007; Langley, Kisorio, & Schmollgruber, 2015; Whitehead et al., 2015).
End of life care education and access to palliative care consultation teams have been proposed as
an intervention to reduce distress around end of life care (Cavinder, 2014; Corley, 2002; Hamric,
2012; Lützén & Kvist, 2012). As a consultation service, palliative care teams aim to relieve
patient suffering through aggressive biopsychosocial symptom management and aid with
complex medical decision making (Morrison & Meier, 2004; Weissman & Meier, 2011).
Through this service, consultation for the primary service is provided through guidance and
education. As research emerges to address moral distress in nurses, clarifying the role of
palliative and end of life education, training, or consultation services would be beneficial to
guide intervention development. This systematic review will seek to identify methods of
palliative and end of life delivery and determine its impact on moral distress in registered nurses
involved in direct patient care. Study objectives will be to 1) identify the study’s
conceptualization of moral distress 2) Identify the mode of delivery and content of palliative or
MORAL DISTRESS AND PALLIATIVE CARE 7
end of life intervention and 3) To assess the impact of palliative and end of life training/
education/ consultation on levels of moral distress.
Methods
Search Strategy, Data Sources, and Study Selection
A systematic electronic search was conducted in EBSCOhost, Academic Search
Complete, Medline, Social Work Abstracts, Open dissertations, Psychology and Behavioral
Sciences Collection, PsychInfo, CINAHL, Web of Science, and Google Scholar databases as
well as ancestral searches in December 2018. The screening of titles and abstracts was done by
this author. Figure 1 shows the detailed search strategy including search terms, yielded hits, and
titles kept for abstract review. Moral distress and palliative/end of life care was searched within
PROSPERO, an international database of systematic reviews in health and social care and
welfare, and no existing systematic reviews or protocols were found. The study included all
quantitative studies since 1987 with quasi-experimental and observational studies published in
English. Qualitative studies including case reports, discussions, editorials, or reviews were not
included. The population under consideration included registered nurses in any setting (ICU,
academic hospital, outpatient clinic, etc) providing care for adults or pediatric patients. Student
nurses were excluded. The main-focus of the studies had to be the use of palliative or end of life
care training, education, or consultation and its relationship with moral distress. All conceptual
definitions of moral distress as well as moral residue and moral stress, however, other concepts
closely related such as moral voice, agency, and emotional distress were excluded. Published
conference abstracts with no full article were also excluded. Identified titles and abstracts were
screened against the inclusion criteria to find potentially relevant papers. The search strategy was
adapted during the search process to account for vague titles.
MORAL DISTRESS AND PALLIATIVE CARE 8
Data Extraction and Quality Assessment Tools
Data was collected from the included articles and assessed for study quality by two
independent reviewers. Methodological quality and risk of bias was assessed using the National
Institute of Health’s (NIH) Quality Assessment Tool for Observational Cohort and Cross-
sectional Studies (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools). The
tool was selected based on the type of studies and methodologies used in the included studies for
review. The NIH Quality Assessment tool consists of 14 criteria and a three-level rating system
(good, fair, and poor). The tool also provides additional pages for criteria guidance to appraise
included studies. Not all aspects of the studies were applicable to the NIH assessment tool, so
The Cochrane Risk of bias tool (Higgins, Altman, & Sterne, 2011) and synthesis robustness was
also chosen to assess study quality.
MORAL DISTRESS AND PALLIATIVE CARE 9
Figure 1: Search Strategy Including Terms, Hits, and Titles Kept
MORAL DISTRESS AND PALLIATIVE CARE 10
Data Synthesis and Analysis
This study incorporated the Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA) checklist for reporting systematic reviews to reflect best practice and
transparency in reporting systematic reviews (Liberati et al., 2010). Because of heterogeneity in
the methodologies, interventions, and outcomes of the included studies, pooling of quantitative
data to perform a meta-analysis was not possible and therefore a narrative synthesis was
undertaken.
The Ryan and the Cochrane Consumers and Communication Review Group (CC & CRG)
(2013) was used to guide the narrative synthesis. A narrative synthesis is encouraged to
investigate similarities, differences, and patterns among study findings. It proposes four
interactive elements: 1) theory development 2) preliminary synthesis of findings 3) exploration
of relationships between studies and 4) assessment of the robustness of the synthesis. The role of
palliative and end of life training theorizing its role in the context of nurse moral distress was has
been explored, the remaining three elements will be discussed.
Results (preliminary synthesis)
Of the 11,409 potentially relevant publications, two published articles and one
dissertation met all the inclusion criteria. A flowchart illustrating the process of study selection is
shown in Figure 2. Characteristics of the included studies are summarized in Table 1, 2 and 3.
The included dissertation by Wolcott and colleagues (2016) discussed three separate studies from
the same data source. One published article summarized two of the three studies within the
dissertation and was excluded (Altaker, Howie-Esquivel, & Cataldo, 2018). There was only one
study with a quasi-experimental design whereas the other two studies were non-experimental
MORAL DISTRESS AND PALLIATIVE CARE 11
cross-sectional designs. All three studies used a version of the Moral Distress Scale with a
variety of other measures of palliative or end-of-life care education, training, and consultation.
Quality Assessment of the Included Studies
Each study included in the review was independently reviewed by an additional reviewer,
initial JO. This author and JO had 100% interrater agreement regarding all three studies.
The likelihood of selection bias was moderate in the trials included in the study. Blinding of
outcome assessors and participants was not possible. Two studies were conducted via e-mailed
newsletter and/or social media and the third was in a single center. Measures used were reliable
and valid. Other than the dissertation, statistical analysis reporting was limited and non-
transparent contributing to result bias and unclear interpretations of the relationship between
independent and dependent variables.
Bosshardt and colleauges (2018) was the only study to measure moral distress across
time but was unable to control for potential confounding variables. Response rates were low or
not reported and confounding variables were a limitation in all three studies. None of the studies
could offer causality or generalizability.
MORAL DISTRESS AND PALLIATIVE CARE 12
Figure 2 Flow diagram of the study selection procedure
MORAL DISTRESS AND PALLIATIVE CARE 13
Characteristics and Outcomes of Included Studies
Only one study explored the impact of a palliative consultation intervention by measuring
levels of moral distress with the MDS-R with pre and post intervention (Bosshardt, 2018). They
also used a mixed-methods design, but the qualitative analysis was not included in the
assessment or data analysis for the purposes of this review. Authors hypothesized a policy
change of allowing nurses to independently consult palliative care without a physician’s order
would contribute to lower levels of moral distress. Although the intervention involved a
palliative consultation service, the authors suggested nurse empowerment would contribute to
distress reduction. They found there were no changes in average MDS scores between rounds but
there was a significant change in the frequency of reported events for 1) provision of less-than
optimal care (14.4% compared with 24.1%, p=.0378), 2) continuation of care for a hopelessly ill
patient (34.6% compared with 23.1%, p=.0397), caring for patients they did not feel qualified to
care for (5.3% compared with 14.8%, p= .0055), and working with other health care providers
were not competent to care for the patient (13.9% compared with 26.9%, p= .0059). The nature
of the methodology doesn’t lend itself to draw conclusions about whether it was the policy
change, palliative care consultation, or the campus wide end of life care education efforts that
took place during that time that impacted findings.
The other two studies utilized a cross-sectional e-mail- based survey to assess levels of
moral distress within the same nurse network, the AACN (Browning, 2013; Wolcott, 2016).
Browning (2013) focused on the relationship between psychological empowerment, moral
distress, participation in end-of-life care conferences, and end-of-life education through a nursing
curriculum, End-of-Life Nursing Education Consortium (ELNEC), along with other
demographic variables. Wolcott (2016) used a slightly different approach also measuring
MORAL DISTRESS AND PALLIATIVE CARE 14
psychological empowerment and moral distress, but incorporated hospital ethical climate,
perceptions of palliative care in the ICU, methods of inclusion, and level of palliative care
education held by nurse participants.
Browning (2013) analyzed results by comparing total MDS, frequency and intensity
MDS scores, as well as subscales of the MDS (individual responsibility, not in patient’s best
interest, and deception). Through correlational analysis Browning (n=277) determined weak but
significant positive associations with higher moral distress frequency and intensity on the item
“not in patient’s best interest” and age of the nurse (r=.0179, p=.01) and ELNEC training
(r=0.185, p= .008). Authors also reported weak, significant positive correlations between
“ELNEC training and the items ‘not in patient’s best interest’ (r=0.194, p=.006) and total score
for moral distress frequency (r=0.165, p=.02).” (p. 148). Nurses who participated in end- of- life
care conferences had a weakly associated reduction in moral distress scores related to the
subscale “deception” (r=-0.191, p=.007).
The regression model within Browning’s (2013) study included total psychological
empowerment scores (PEI) and demographic variables. No table was provided for further
interpretation, but authors reported 28.9% of moral distress frequency variance was explained by
the model (F (2,171) = 7.801, p < .01). Two predictors, ELNEC training (β=-.215, p<.01) and
PEI total scores (β=.222, p<.01) explained 8.40% of moral distress frequency variance. It is of
note, within this study, only 16 respondents had ELNEC training.
Wolcott (2016) in her dissertation used correlations, regression, analysis of variance, and
T-tests to explore the relationship among access to a palliative care consultation team, palliative
education, psychological empowerment, ethical climate, and moral distress using MDS scale
revised (MDS-R). Among participants (n=235), 73% (n=171) reported having access to a full
MORAL DISTRESS AND PALLIATIVE CARE 15
palliative care team defined as specialist palliative care physicians, nurses, social workers, and
spiritual care practitioners. Authors determined access to a palliative care team did not influence
the association between ethical climate and moral distress or empowerment and moral distress.
They did determine significant differences of total MDS-R scores (n= 238) between nurses who
had access to a palliative care team (M= 102.3, SD= 57.2) and nurses who did not (M= 79.8,
SD= 49.4).
Through multiple regression analysis (N= 218), authors explained 37.7% of the variance
within moral distress scores was explained by ethical climate, psychological empowerment,
access to full palliative care team, number of beds in unit, ethnicity, years of experience,
educational degree, and facility. Access to a full palliative care team was a significant contributor
(β= .152, F(1205)= 6.791, p =.01). Other factors which significantly contributed were ethical
climate (β= -.379, F(1205)= 39.589, p = .001), number of beds in unit (β= .229, F(1205)=
15.335, p<.001), African American nurses vs Caucasian, Asian, and “other” (β= -0.193,
F(1205)= 10.317, p= .002), and educational degree (F(3205)= 5.932, p= .001). Within
educational degree, associate’s vs diploma in nursing (β= .238, F=7.431, p= .007), BSN vs
diploma in nursing (β= .425, F=17.530, p <.001), and MSN and beyond vs diploma in nursing
(β= .258, F= 8.874, p=.003) were all significant.
MORAL DISTRESS AND PALLIATIVE CARE 16
Study design Measure Study setting
Number of participants
Intervention/ Variables
Analysis Outcome/ Dependent Variable(s)
- Quasi-experimental One Group Pretest-Posttest
- Web-based survey
Moral distress Survey Revised (MDS-R)
700- bed academic medical center
200 round 1 (10% response rate)100 round 2(5% response rate)
Policy change allowing RNs to consult palliative independently of physicians
Descriptive
Chi-square
- No MDS mean differences between rounds
- Higher distress around perceived coworkers’ competency and feeling qualified to care for patients after policy change
- Lower distress with continued care for a hopelessly ill patient after policy change
- Decreased frequency of perceived futile care being provided after policy change
Study design
Measures Study setting
Number of participants
Intervention/ Independent
Analysis Outcome/ Dependent
Table 1 Bosshardt, Coyne, Marsden, Su, & Melvin (2018). Palliative care consultation policy change and its effect on nurses’ moral distress in an academic medical center.
MORAL DISTRESS AND PALLIATIVE CARE 17
Variable(s) Variable(s)- Non-experimental Cross-sectional
- Web-based survey
MDS-R
Hospital Ethical Climate Survey (HECS)
Psychological Empowerment Instrument (PEI)
Questionnaire assessing perceptions of Palliative Care (PC) in ICU, methods of PC inclusion, and level of PC education
American Association of Critical-Care Nurses (AACN) email newsletters/ social media
238 nurses (no response rate reported)
- Access to specialist PC team
- PC education topics
Descriptive
Correlations Multiple Regression
ANOVA
T-tests
- 73% (n=173) of nurses claimed access to PC
- PC does not influence association between ethical climate and MD
- Higher MDS mean score associated with having access to PC team
- Higher MDS scores predicted by access to a full palliative care team as well as other factors
Study design
Measures Study setting
Number of participants
Intervention/ Independent Variable(s)
Analysis Outcome/ Dependent Variable(s)
Table 2 Wolcott. (2016). Moral distress of ICU nurses and palliative care in the ICU
MORAL DISTRESS AND PALLIATIVE CARE 18
Non-experimental cross sectional
Web- based survey
MDS
PEI
personalized demographic survey assessing End-of- Life Nursing Education Consortium (ELNEC) training, end-of-life education in last year, collaboration in end-of-life care conferences
AACN email newsletters
277 nurses (.35% response rate)
psychological empowerment
demographics from survey (includes ELNEC training, end -of-life care conferences, and end-of-life education)
descriptive
correlations
multiple regression
- 5.8% (n=16) participated in ELNEC
- 54.6% (n=151) had end-of-life care education
- Higher MDS frequency with ELNEC training
- Lower MDS frequency scores addressing impending death honestly with patient associated with participation in end-of-life care conferences
- Higher MDS scores within “not in patient’s best interest” subscale associated with ELNEC training
- Higher MDS scores related to perceived futile care associated with nurses advanced in age and who had ELNEC training
- Higher MDS frequency scores predicted by ELNEC training
Unique to this study was the examination of specific palliative care education topics in
moral distress among nurses. Wolcott (2016) identified five components of palliative education
Table 2 Browning. (2013). Moral distress and psychological empowerment in critical care nurses caring for adults at end of life.
MORAL DISTRESS AND PALLIATIVE CARE 19
as: pain management, symptom management (anxiety/ depression), goals of care conversations,
discussion of suffering, and code status. Significant differences were found for all topics except
code status. Nurses with education in pain management had total MDS score of 94.6 (sd= 57.6)
compared to nurses without education in pain management (72.8) (n=213, t(24.7)= -2.3, p=.03).
Nurses with education in anxiety and depression had MDS score of 91.3 (sd= 58.9) compared to
nurses without education who had a total score of 67.4 (n=183, t(111)= -3.4, p=.001). Nurses
with education around communication around prognosis had MDS score of 90.6 (sd= 59.7)
(n=169, t(157.4)= -3.0, p=.003) with a mean difference of -21.2 compared to nurses without
education. Nurses with education around GOC had MDS score of 90.2 (sd=59.0) (n=178,
t(129.4)= -3.8, p<.0001) with a mean difference of -26.6 compared to nurses without education.
Nurses with education around Suffering had MDS score of 90.9 (n=167, t(170.7)= -2.8, p=.005)
with a mean difference of -19.4 compared to nurses without education. Additionally, nurses who
had education had less total moral distress scores and distress intensity, but no changes in
frequency.
Discussion (exploring relationships)
This section attempts to discuss the studies according to their aims and objectives, then
identify “how the results of the studies might be affected by factors such as methodological
differences between studies, or variable characteristics of the populations studied” (Ryan &
Cochrane Consumers and Communication Review Group, 2013, p. 4). Within the three articles,
three distinctive strands emerged.
1. Heterogeneity among palliative and end-of-life variables
2. Measurement and definition of moral distress
3. Selection bias and confounding variables
MORAL DISTRESS AND PALLIATIVE CARE 20
Heterogeneity among variables
There were three ways palliative or end of life care was used as an intervention among the
included studies: access to palliative consultation teams, palliative or end-of-life care education,
and involvement in end-of-life care conferences. Bosshardt and colleagues (2018) aimed to
address whether nurses’ ability to consult palliative care teams independently of physicians
would promote empowerment and therefore decrease levels of moral distress. They discovered
no differences in total moral distress scores after the policy change. Authors theorized campus
wide end-of-life education may have played a role in selection bias and higher distress around
perceived coworker competency and nurses feeling qualified to care for patients. The frequency
of palliative consultation before and after policy change was not reported. It was unclear how
they measured “access” to consultation teams.
Wolcott also sought to establish a relationship between access to palliative care consultation
teams and determined access was associated with higher moral distress levels. A questionnaire
was used to determine access to palliative care through multiple questions and the questionnaire
was provided in the final report. The author also explored education topics and found over 20%
of nurses in the sample had no palliative care education. However, for those who had education
in pain and symptom management, goals of care, suffering, and prognosis had less moral
distress.
Browning (2013) was also interested in the role of education and studied the use of ELNEC
training, end-of-life focused continuing education, and participation in end-of-life care
conferences. Nurses who were older and had ELNEC training had more frequent distress around
following family or physician orders incongruent with their opinion and terminally ill patients
MORAL DISTRESS AND PALLIATIVE CARE 21
receiving unnecessary medical treatments. The frequency of distress with perceived deceptive
medical treatment was lessened for nurses who participated in end-of-life care conferences.
Measurement and Definition of Moral Distress
In 2012, Hamric addressed challenges and opportunities present in existing research on moral
distress. Two of her recommendations were for future research to have consistency in defining
moral distress and include the use of valid instruments. Included studies cited Jameton (1984) as
the first to introduce moral distress and discussed the impact of constraints. The study by
Bosshardt and colleagues (2018) was the only study to discuss other definitions of moral distress
citing Fourie (2017) and Sirilla (2014).
All included studies used a version of the Moral Distress Scale (MDS) as their measurement
tool. Browning (2013) used the original MDS developed by Corley, Elswick, Gorman & Clor
(2001) while Bosshardt and colleagues (2018) and Wolcott (2016) used MDS revised (MDS-R).
The MDS was developed based on existing research, interviews with staff nurses, consultation
with Jameton, and consensus from nursing PhDs. The MDS consists of 32 items and resulted in
three separate factors: responsibility (α= .97), not in patient’s best interest (α= .82), and
deception (α= .84). Hamric, Borchers, & Epstein (2012) conducted another revision to the scale
(MDS-R) and expanded it to include other health care professionals. The MDS-R is a 21- item
scale with 5-point Likert scales to reflect frequency and intensity (α= .88). Each of the revisions
of the MDS is revised to reflect recent literature.
Heterogeneity was also observed in measurement interpretation which contributed to
comparison challenges. For example, Bosshardt et al. (2018) organized the Likert frequency
scores of zero to four arbitrarily into “never” or “infrequently” (scores of zero, one, or two) and
“frequently” and “very frequently” (scores of three and four). Whereas, Wolcott (2016) offered
MORAL DISTRESS AND PALLIATIVE CARE 22
no classification but reported averages in relationship to their total possible scores (zero-336) and
frequency and intensity subscales (zero-84). Browning (2013) also subjectively classified scores
on the MDS Likert scores of one to seven by groupings of “low” (0-2.33), “moderate” (2.34-
4.66), and “high” (4.67-7).
Selection bias and confounding variables
All three studies included in the review were unable to control for participant selection
bias and confounding variables. Authors discussed selection bias within their limitations and
acknowledged nurses who are interested in palliative issues may be more willing to participate in
their study. Both Wolcott (2016) and Browning (2013) used multiple regression to control for
potential confounders. The value was the ability to see the contribution of the palliative or end of
life intervention in comparison to other variables. According to Corley, Hamric, and Hamric and
colleagues (as cited in Wolcott, 2016), there is “no single factor independent of environment is
consistently responsible for moral distress levels” (p. 81). Determining whether palliative or end
of life care contributes to the reduction of moral distress levels may require advanced analysis
such as structural equation modeling.
The t-test and chi-square analysis was most commonly used included studies to test for
differences between groups or variables. Although these tests allowed authors to argue there is a
difference, they do not allow the authors to determine why these differences exist. This put limits
on the results and ability to draw conclusions on the role of palliative or end of life interventions.
Future research could benefit from more rigorous methods to randomize participants or
statistically control for confounding variables.
Awareness and constraints
MORAL DISTRESS AND PALLIATIVE CARE 23
Although education has historically been proposed as an intervention to reduce moral
distress, authors theorized the increased awareness may become another internal constraint.
Corley’s (2002) conceptual framework on moral distress proposed palliative care may support
nurses’ moral courage enabling them to morally act and prevent moral distress (Bosshardt et al.,
2018).
The level of support palliative can offer may depend on its level of integration in the
hospital structure (Wolcott, 2016). Nurses’ attitudes, perceptions, and understanding of palliative
care may influence whether palliative is appropriate and helpful for the patient in that setting.
She went on to say palliative consultation services can “elevate expectations of care for dying
patients…but unless the palliative care team is active in the unit, these expectations may face
barriers” (p. 30). These barriers can create more constraints which would increase distress.
Education may not be enough to reduce these barriers and pose threat of becoming an additional
barrier itself.
Limitations (synthesis robustness)
This is the first systematic review on the role of palliative care in the moral distress
literature. The review employed a narrative synthesis which offered the ability to discuss ideas
and theories from the included studies. A “common criticism of narrative synthesis is that it is
difficult to maintain transparency in the interpretation of the data and development of
conclusions” (NIHR CRSU, n.d.). However, the use of defined inclusion/exclusion criteria,
number of databases used, the search strategy, quality assessment of the studies, and discussion
of findings contributed to transparency and rigor.
Moral distress is not unique to nurses and recent literature has expanded its focus to
include all healthcare professionals (Whitehead, et al., 2015). There may be other empirical
MORAL DISTRESS AND PALLIATIVE CARE 24
studies which would have been included had the inclusion criteria not been specific to nurses.
Future research may include healthcare professionals to get a broader understanding of palliative
and end of life care training in moral distress.
The narrative synthesis was also limited by a lack of articles regarding the specific topic
and the way moral distress is measured and analyzed. Hamric (2012) shared ways researchers
can progress moral distress research and although many advancements have been made, rigorous
interventional studies continue to lag. Solid conclusions are difficult to identify given the amount
of bias and conflation in study variables, measurement, and analysis.
Conclusions
Moral distress is a conceptually complex construct. Since it’s introduction in the 70s and
80s, researchers have exhausted our understanding of how it exists in real world settings. As
Hamric (2012) encouraged, more work is needed to evaluate interventions and whether moral
distress can be mitigated when situational factors cannot. Future studies should examine moral
distress longitudinally and further refinement of the study to establish construct validity is
necessary.
MORAL DISTRESS AND PALLIATIVE CARE 25
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