The concept of moral distress is not new to nursing. As early as 1984 Jameton described moral distress as occurring when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Nurses may experience moral distress when confronted with chosen treatment options that they believe are not be in the best interest of the patient, and/or do not mesh with their sense of right and wrong. Although the nursing literature documents moral distress in the clinical area, it does not address moral distress in academia. Yet anecdotal evidence indicates that moral distress also occurs in academic institutions. The author begins this article by describing the experience of moral distress and suggesting that moral distress occurs not only in the clinical setting, but also in the academic setting. This is followed by a review of the literature related to moral distress in nursing education and a discussion of the seeds of moral distress in nursing education, such as dishonesty, including cheating and plagiarism; grade inflation; and incivility. The author concludes by identifying the professional implications of moral distress in nursing education.
Key words: Nursing education, academic dishonesty, moral distress, ethical climate, collegial incivility, grade inflation, nursing students, nurse educators, responsibility, accountability, cheating, plagiarism, college students, academia.
The nursing profession has traditionally held to a high standard of moral behavior and ethical practice. Nurses in clinical practice frequently report the distress they experience when, for example, a standard that they believe in is compromised in some fashion. Other times this distress occurs when the nurse does not believe that the treatment being provided to the patient is in the best interest of the patient, or does not mesh with the nurse’s sense of right and wrong. Nurse educators, through anecdotal conversations and comments, have shared with this author the moral distress they have experienced when the administration of their educational unit makes a decision they do not feel is in the best interest of the student or the nursing profession. The following scenarios, although fictional, represent anecdotal examples of moral distress in nursing education.
William is a 24 year old nursing student who has struggled from the time he entered the nursing program. Each semester brings new challenges, and his grades skim the passing point. He is just getting by. He somehow reaches his senior year, unable to assemble grammatically correct sentences, organize a research paper, or follow the dreaded APA format as taught or described in his manual. He does his best and turns in his final paper. His professor is dismayed with the paper and returns a failing grade for his project. He appeals to her angrily, saying “I have never had a grade like this before.” She is perplexed because she knows there are many written assignments in the nursing program and wonders how he could have gotten to this point and still have passing grades. She feels she should give him the grade he has earned, but the dean has told her, “you cannot stop him now, he is about to graduate.” She angrily wonders why her colleagues have not dealt with his writing appropriately. Distressed, she feels like she is shouldering responsibility for what her colleagues should have done semesters ago. Yet she knows she cannot override her dean in this situation.
Solange is a 35 year old naturalized citizen from Uruguay. She is a transfer student in the nursing program. Because she is not a native English speaker, she struggles to take tests and write papers. She was admitted to the nursing program because she had the required grade point average and took ‘English as a Second Language’ classes at her local community college. Although she performs well in the clinical area, and it is clear that she makes a connection with patients, she now qualifies for academic dismissal due to her low grades on classroom assignments and low course grades. She is a single mother who commutes to school daily from an hour and a half away and works at a part-time job on the weekends. She is appealing for a second chance to stay in the program so that she can graduate and make a living for her children. The dean considers her appeal, worrying about what lies ahead for Solange and her young family if she doesn’t graduate. The dean also knows that Solange has incurred significant debt to study nursing. Yet the University requires that given her consistently low grades she must be dismissed. The dean knows that she has an obligation to the University to follow the University policy and to the public to send only well-educated, prepared individuals into the healthcare workplace. This dean is experiencing considerable distress.
Stories such as these are frequently shared verbally when nursing educators get together. The frequent sharing of these stories suggests that nursing faculty, as well as nurses in clinical settings, indeed experience moral distress. The author begins this article by describing the experience of moral distress and suggesting that moral distress occurs not only in the clinical setting, but also in the academic setting. This will be followed by a review of the literature related to moral distress in nursing education and a discussion of the seeds of moral distress in nursing education, such as dishonesty, including cheating and plagiarism; grade inflation; and incivility. The author will conclude by identifying the professional implications of moral distress in academic settings.
The Experience of Moral Distress
Moral distress as a concept is not limited to nursing. It can be experienced in all professions and in all work settings. Austin, Rankel, Kagan, and Lemermeyer (2005), in their study of moral distress in psychologists, defined moral distress as “the state experienced when moral choices and actions are thwarted by constraints” (p.197). Using the language of moral reflection among professors, Brown and Gillespie (1999), in their paper on moral distress in universities, also described moral distress as an experience of being constrained from doing the right thing,
Jameton (1984) offered the first definition of moral distress in the nursing literature. He stated that moral distress is the stress that occurs “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). More recent authors, such as Kopala and Burkhart (2005), and Corley, Elswick, Gorman, and Clor (2001), have broadened that definition to include personal responses, for example pain and disequilibrium resulting from obstacles that are found in the clinical workplace. Hardingham (2004) described moral distress as “arising when there is an inconsistency between one’s beliefs and one’s actions” (p. 128). Schluter, Winch, Holzhauser, and Henderson (2008), in their detailed review of the literature on moral sensitivity and hospital ethical climate, noted that “nursing staff definitely appear to be experiencing moral frustration and guilt as a result of being prevented from providing the care they wish” (p. 318). The healthcare literature has generally described moral distress as it occurs within the clinical setting, and has centered the discussion on the experiences of nurses and others delivering direct patient care. This limited, albeit important, emphasis on moral distress in direct care settings points to a need to investigate whether moral distress is occurring in other settings, such as academia.
Review of the Literature Related to Moral Distress in Nursing Education
This section will offer a review of the literature. First it will consider moral distress occurs in nursing education. Next this section will provide a review of articles related to ethical climate and moral distress. Finally it will offer a review of research tools used in research studies on moral distress.
To conduct this review I, the author, searched the databases of CINAHL, CINAHL Plus, and Science Direct Health and Life Sciences College Edition for information using the key words of: nursing education, ethical dilemmas, moral distress, ethical climate, collegial incivility, grade inflation, nursing students, nurse educators, responsibility, accountability, cheating, and college students. I extended the search to the earliest year available in the databases ranging from 1962 to the present. Additionally I searched the nursing education journals of Nursing Education Today, Journal of Nursing Education, and Nursing Education Perspectives using the key words mentioned above.
Moral Distress in Nursing Education
Moral distress as a phenomenon has been confirmed by researchers such as Hamric and Blackhall, (2007); Corley, Minick, Elsick, and Jacobs, (2005); and Gutierrez, (2005). However, virtually all of the healthcare-related research on moral distress that was found during the literature search occurred in clinical practice settings; this research was frequently associated with end-of-life situations. No reports were found describing moral distress in academia, even though the anecdotal evidence provided by numerous professors in schools of nursing throughout the United States has strongly suggested that moral distress does exist in schools of nursing. The anecdotal reports have suggested that moral distress in the academy seems to be associated with activities such as student incivility, student cheating and plagiarism, colleague incivility, bullying, academic admission standards, standards of the profession, and cultural concerns. Although literature has pointed to the existence of these activities in nursing schools, it has not moved to the point of connecting them to moral distress.
...the necessary step of “recognition” or labeling of moral distress by faculty will be difficult, yet important. Research outcomes suggest that moral distress may be expressed through physical symptoms, such as trouble sleeping, headaches, shaking, and/or gastrointestinal changes, as well as psychological symptoms, such as feelings of anguish, frustration, anxiety, and/or guilt (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005; Gutierrez , 2005). Pendry (2007) encouraged nurses to recognize that moral distress may be what they are experiencing as they are confronted with, and seek to resolve difficult situations. To date anecdotal evidence has indicated that faculty are voicing symptoms such as sleeplessness, anger, or confusion related to painful experiences, but they are not using the term moral distress. In nursing education, the pain and disequilibrium that exist during stressful situations with students, faculty, or administration, may not (as yet) be defined as moral distress. If that is the case, the necessary step of “recognition” or labeling of moral distress by faculty will be difficult, yet important.
Brown and Gillespie (1999) stated that “faculty, staff, and administrators [in universities] must assume a fair degree of moral agency,…at the same time [that] universities...present impediments to moral agency that may be the cause of moral distress” (p. 36). For example, in nursing education, there may be a disconnect between the college’s expectation of the placing of an adequate number of students “in the seat” so as to provide tuition income from an adequate number of students and the placing of only the best students in the seats. The faculty, experiencing the pain and guilt related to moral distress due to these conflicting expectations, are left to deal with the fallout of poor student performance, remediation, and progression, and sometimes to watch students graduate who may be ill-prepared to practice.
Relationship between Ethical Climate and Moral Distress
Moral distress among faculty may lead to ‘brain drain’ from the faculty ranks... Olson (1995) studied ethical climate as a concept, noting its similarities to the concepts of ‘moral climate,’ ‘corporate ethical climate,’ ‘ethical work climate,’ ‘ethical environment,’ ‘ethical or moral culture or corporate culture,’ and ‘ethical dimension of the organizational culture.’ She reported that all of these terms were “used to describe the same phenomenon” (p. 87), adding that “an organization’s history, formal structures, mission, philosophy, and values influence perceptions of ethical climate” (p. 88). In 2002 Olson stated that the ethical climate of an organization often consists of “...perceptions of organizational practice and conditions that facilitate the discussion and resolution of difficult patient care issues” (p.3). She went on to describe ethical climate as “one type of organizational climate” [that can be] “managed and changed in order to improve the workplace environment” (p.3).
Provision 6.3 of the American Nurses Association (ANA) Code of Ethics for Nurses (2001) has called for nurses to share responsibility for the healthcare environment. It has described a moral environment as that which “encourages respectful interactions with colleagues, support of peers, and identification of issues that need to be addressed” (p. 21).
There is some evidence that the symptoms of moral distress surface more readily when the ethical climate of an organization is not supportive and/or respectful of nursing practice. Pauly, Varcoe, Storch, and Newton (2009) reported a negative correlation between ethical climate and the levels of moral distress, noting that “the higher the score for the ethical climate (indicating a more positive ethical climate) the less intense the reported levels of moral distress” (p. 568). These authors further noted that there seem to be a multitude of factors that affect ethical climate, such as peers, patients, managers, hospitals, and physicians. Kim, Park, You, Seo, and Han (2005) asserted that an ethically sensitive environment is one of the most important factors in decision making; it enables nurses to make sound observations and recognize potential consequences when dealing with difficult ethical situations.
Corley, Minick, Elswick, and Jacobs (2005) used the term ethical environment to describe a workplace environment supporting open reflection and discussion of the work of nurses as they practice. Further, they asserted that an ethical environment supports both ethical decisions related to patient care and respectful treatment of staff via policies, organizational philosophy, and/or conflict resolution procedures.
In a summary of the research findings available (Corley, et al, 2005; Olson, 1998, Pauly et al., 2009) support the assertion that the ethical climate in hospitals may be related to moral distress. I did not locate any research findings that spoke to this relationship in the college environment. Since schools of nursing are located within the academic milieu of colleges and universities, the environment of teaching and learning in nursing education may well include the same “impediments” that Brown and Gillespie (1999) discussed in their commentary on moral distress in universities (see above). Research is needed in this area to gain hard evidence of the existence of moral distress in nursing education so that the distress can be discussed openly and studied.
Much of the research literature that has assessed moral distress among nurses in the workplace has used Corley’s Moral Distress Scale (Corley, Elswic, Gorman, & Clor, 2001; Hamric & Blackhall, 2007); McDaniel’s Ethics Environment Questionnaire (McDaniel, 1997); and/or Olson’s Hospital Ethical Climate Survey (1998). Research reports (Corley, Elswic, Gorman, & Clor, 2001) and commentary (Austin, Lemermeyer et al., 2005) have indicated that using tools to measure such a subjective, variable-laden phenomenon as moral distress must be framed by explaining carefully each context in which they are used. To date all research using these tools has been conducted on inpatient nursing units, including, for example, critical care, oncology, and neonatal intensive care units. These tools could be adapted for use in non-acute areas of nursing, such as education, community health and/or outpatient settings.
Seeds of Moral Distress in Nursing Education
...academic dishonesty, grade inflation, and/or bullying may lead to moral distress that may ultimately influence faculty job satisfaction and student learning. Nurse educators, through anecdotal conversations and comments, have indicated that there are situations in academia that plant the seeds of moral distress. An environment that includes academic dishonesty, grade inflation, and/or bullying may lead to moral distress that may ultimately influence faculty job satisfaction and student learning. Olson (2002) has made the case for attending to the clinical work environment in order to increase nurse retention and improve patient satisfaction. An academic organizational climate that allows academic dishonesty, grade inflation, and incivility to proliferate may result in loss of faculty and dissatisfaction among students. Moral distress among faculty may lead to ‘brain drain’ from the faculty ranks; the nursing profession cannot afford to allow further erosion of nurse faculty numbers. It may also result in poor learning outcomes for students, as well as poor outcomes on the National Council (of State Boards of Nursing) Licensure Exam, or poor performance as new graduates. The following sections will address these ‘seeds of moral distress.’
...the use of technology may increase the opportunities for academic dishonesty. Tippitt et al. (2009) have described the increasingly high-stakes environment of higher education, in which “a student’s retention in or progression through a program, scholarship or loan, parental approval, or other significant factor is dependent on student success” (p. 239). These authors have called for “an environment that fosters academic integrity.…and cultural change” (p. 239). Tippitt et al. (2009) challenged the profession to pay close attention early on to these ethical issues as they “engage in the preparation of nurses” (p. 239). Rosenkoetter and Milstead, (2010) have offered similar advice in their recent revision of a code for nurse educators, the only such ethics code developed since 1983.
Increasingly the use of technology may increase the opportunities for academic dishonesty. Academic programs throughout the country now commonly use technology to deliver courses conveniently as well as to give tests online. In these situations cheating can be done with ease, using cell phones, digital cameras, mini microphones, and other devices. Years of research have indicated that a large majority of students have cheated at one time or another during their college education (McCabe & Trevino, 1993; McCabe & Trevino, 1997; McCabe, Trevino, & Butterfield, 2001). Maintaining an ethical environment may be even more challenging today than it has been in the past.
Sometimes even if faculty seek to address students’ unethical behaviors, appeal decisions result in acquittals. Academic dishonesty, such as cheating and plagiarism, when they are not dealt with through established means, for example through honor codes, can create conditions that affect both faculty and students in a negative manner. Sometimes even if faculty seek to address students’ unethical behaviors, appeal decisions result in acquittals. Bavier (2009) noted there are times when “...appeals of nursing faculty decisions are decided by non-nurse faculty who do not understand the seriousness with which [nurses] view such infractions” (p. 5). Faculty are affected negatively by these experiences. Tippit et al. (2009) appropriately asked “How can nursing education ignore something that may impact patient care and contribute to unethical clinical practice during the completion of an academic program, and potentially in the nurse’s later professional practice?” (p.240). Symptoms of moral distress or frustration may begin to surface in students who see the negative behaviors continue. This frustration occurs when students know what should be done, based on their own moral sensitivity, but do not see it happening. Then they, too, experience moral distress. Academic dishonesty, high tech cheating, and plagiarism in an educational program have the potential to have a negative effect on practice after graduation. Harper (2006) maintained that the implications for the nursing profession were profound as students who engaged in academic dishonesty were more likely to practice dishonestly. She wrote: “If academic misconduct is a precursor of professional misconduct as the literature indicates, it is imperative that the nursing profession take immediate action to ensure that the ethical fabric of the profession is maintained” (p.675-676).
Reported unethical behaviors must lead to consequences when evidence is found. If this does not occur, a climate of acceptance of dishonesty may prevail. McCabe and Trevino (1993) observed:
The strong influence of peers' behavior may suggest that academic dishonesty not only is learned from observing the behavior of peers, but that peers' behavior provides a kind of normative support for cheating. The fact that others are cheating may also suggests that, in such a climate, the non-cheater feels left at a disadvantage (p. 533). A climate that ignores unethical behaviors in students, or faculty, breeds an attitude that may be transferred to nursing practice and patient care. In the academic environment, honor codes must be robust and must be enforced. Incidents in which those in authority turn their heads or because of fear of litigation refuse to charge students with academic dishonesty must not occur. Too much is at stake in the profession and in the lives of patients and families for these behaviors to continue.
The practice of passing students along through a program because faculty are loathe to fail students does little to promote an ethical climate... Nursing faculty may find themselves in the difficult position to be the first to surprise a student with a poor or failing grade. The practice of passing students along through a program because faculty are loathe to fail students does little to promote an ethical climate and does much to create distress among faculty and perhaps even endanger a program or the public. The reputation and credibility of a nursing program may suffer if its graduates are perceived to be poor performers. Of even greater concern is the potential link to unsafe patient care. Scanlon and Care (2004) stated that “educational institutions are the gatekeepers to the profession. By allowing weak or mediocre students to progress and ultimately graduate, we are not only jeopardizing the reputation of the profession, but we are placing clients at risk” (p.477). Anecdotal evidence has suggested that this happens more frequently than the profession would like to admit. External pressures such as regional or national nursing shortages may add to the overall tendency toward grade inflation as better grades yield more graduates. Similarly, internal pressures such as the desire for positive course evaluations or popularity among professors has been linked to the propensity for grade inflation (Eiszler, 2002). When faculty who do grade according to a student’s performance encounter the anger of students who have experienced several semesters of easy grading, they feel pressured by those around them to conform and pass the student regardless of the student’s accomplishments or lack thereof. These situations also lead to moral distress.
Collegial incivility may be exhibited through behaviors such as rudeness, open disdain, passive aggressiveness, bullying, psychological abuse, or deliberate undermining of activities. These types of incivility may lead to a non-supportive organizational climate in which faculty feel pressured by administrators and/or peers to look the other way, and thus fail to support the person experiencing such incivility. Beasley (2010) asserted that “faculty incivility creates a destructive culture that denies students the opportunity to learn, grow, and develop in a profession that is known for its compassion” (p.4). Moral distress among nurse educators may arise from different situations than those related to patient care. However, the outcome of this moral distress are the same, namely, an organizational climate that does not support healthy collegial behaviors.
Moral distress among nurse educators may arise from different situations than those related to patient care. However, the outcome of this moral distress are the same... This article began by suggesting that moral distress occurs not only in clinical areas but also in academic settings. Anecdotal evidence indicates that moral distress does exist in academia. The symptoms of moral distress described above as occurring in the clinical arenas, for example mental pain, sleeplessness, and guilt, are similar to those described by nursing faculty in anecdotal stories describing the seeds of moral distress. However, moral distress itself has not yet been described in the literature addressing academic environments. This absence implies that research is needed to document the extent to which moral distress exists in academic settings.
As both an administrator and a faculty colleague, I believe that there are also certain assumptions in place in academia that have not been adequately examined. For example, required coursework in ethics, and lip service to the ANA Code of Ethics for Nurses may lead to an assumption that students are receiving the ethics education that they need and that it is improbable that situations leading to moral distress will arise in academic settings. Research is needed to determine the validity of this assumption. Even more dangerous is the assumption that integration of ethics content throughout the curriculum will result in ethical behavior on the part of students and graduates. Unfortunately the content may be so diluted through “integration” that students don’t even remember studying the content. Again research is needed to compare the effectiveness of integrating ethics into the curriculum compared with offering a specific course(s) in ethics.
Tippit et al. (2009) have called for a positive proactive approach that builds an environment of academic integrity with expectations of honesty, trust, respect, integrity, and responsibility. Similarly, Kenny (2007), in her article about plagiarism and its relationship to behaviors in professional practice, has called for nurse educators to build and role model a culture that supports integrity. Kenny wrote:
Plagiarism is clearly a serious issue for students who are undertaking training to enter a profession where integrity, honesty and trustworthiness are paramount to the nurse-patient relationship. It is thus essential that nurse educators contribute to building a culture of integrity and professionalism demonstrable throughout the academic community from the commencement of training” (p.18).
Clark (2010) added to the discussion by including civility as a ‘must’ in nursing education in-order-to create an environment of trust and collaboration, writing “when nursing faculty, students and clinical practitioners engage in meaningful dialogue and work together to resolve conflict, the potential for civility is enhanced, and safer learning and practice environments are created” (para. 6). Conscious and consistent teaching about ethical behaviors can decrease moral distress by lessening the probability that students will participate in inappropriate behaviors that might lead to moral distress among faculty members.
Even more dangerous is the assumption that integration of ethics content throughout the curriculum will result in ethical behavior.... Activities such as academic dishonesty, grade inflation, and collegial incivility are a danger to the academic environment and ultimately the nursing profession. These situations can create moral distress in academia. Nursing is consistently listed as the most trusted profession; yet the public’s trust in nursing could quickly erode if the profession does not attend to maintaining ethical standards in academia today. If we as a profession fail in doing so, a culture of tolerance for the events leading to moral distress will grow.
This is not to say that a punitive atmosphere should be advocated. Instead a culture of integrity, one that fosters trust, collaboration, and a desire for the highest ethical behavior, should infuse the fabric of both the academic and clinical environments in nursing so as to offer the highest quality of care and decrease the incidence of moral distress within the profession.
Anecdotal evidence strongly suggests that moral distress does exist in the educational workplace. This evidence indicates that interpersonal conflict emerging from issues such as cheating, grade inflation, or incivility leads to moral distress in nurse educators. Although this moral distress may be rooted in situations that are not commonly found in the clinical workplace, it can yield emotional and physiological responses similar to those described in the research on clinical moral distress. Furthermore, this moral distress in education may result in turnover among nurse educators, something we can ill afford in this era of faculty shortage.
Although much has been written about moral distress in the clinical setting, a search of the nursing literature identified no research to date addressing moral distress in academia. Nor have any research instruments been developed to assess the presence of this distress. Such research is needed. Initial studies using qualitative methods are recommended for gathering data that will guide instrument development. Additionally instruments used in clinical practice might be adapted for use in the education arena. This research is essential in-order-to decrease moral distress in academic settings and strengthen the education of nursing students, our future nursing caregivers.
Kathryn M. Ganske, PhD, RN
For the past three years Dr. Ganske has served as the Director of the Division of Nursing at Shenandoah University (SU) in Winchester, VA, where she also teaches graduate and undergraduate classes in ethics, bioethics, and genomics. She has worked in various capacities in nursing education for a total of 16 years. She holds a BSN from Indiana University (Indianapolis, IN), a MSN from George Mason University (Fairfax, VA), a MA in Bioethics from the University of Virginia (UVA) (Charlottesville, VA), and also a PhD from the University of Virginia. She became interested in ethics as a doctoral student at UVA while studying the ethical implications of family caregiving. She is a former Chair of the SU Institutional Review Board and currently serves on the Ethics Committee at the Winchester Medical Center. She is also a member of the Virginia Nurses Association Committee on Ethics and Human Rights, and was recently appointed to serve on the American Nurses Association Ethics and Human Rights Advisory Board. She is currently completing work on a qualitative study of moral reasoning in clinical nurses.
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Clark, C. (2010). Why civility matters. Reflections on Nursing Leadership, 36(1). Retrieved March 29, 2010, from www.reflectionsonnursingleadership.com/Pages/Vol36_1_Clark2_civility.aspx
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