Our article about care leaders’ moral distress was published in thejournal Scandinavian Journal of Caring Science in 2022. The article was a result of my master’s thesis with the topic moral distress. The article was made during the COVID-19 pandemic, and this had a major impact on the study findings. Due to the pandemic the concept moral distress was raised more and more in the healthcare but also in media. Besides the COVID-19 impacts, moral distress is also an underlying reason to the mass leavings in the healthcare. It is why many caregivers have chosen to leave their professions in recent years and given its major impact on care, the topic should be further researched (Morley et al., 2020).

An increased emphasis on efficiency in healthcare today has led to ethical conflicts becoming highly common in care environments (Aitamaa et al., 2010; Ganz et al., 2015). Ethical conflicts can arise, e.g., when top management introduces changes or issues directives that conflict with care leaders’ ethical values (Ganz et al., 2015). This in turn can result in care leaders experiencing moral dilemmas or stress (Ganz et al., 2015). Attention has been placed on the “moral distress” that caregivers may experience (Vittone & Sotomayor, 2021) when they are unable to act in the way they wish because of an external obstacle (Faraco et al., 2022; Miljeteig et al., 2021)). Moral distress has been identified as the reason underlying why many caregivers have chosen to leave their professions in recent years and given its major impact on care, the topic should be further researched (Morley et al., 2020). Used alongside the terms “ethical problems” and “ethical stress”, moral distress is defined as a psychological imbalance that occurs when people are aware of the ethically appropriate action that a situation would require but cannot perform this action due to external obstacles (Corley et al., 2005; Savel & Munro, 2015). Moral distress is thus linked to moral judgment: when a person understands what the “right thing” to do is but is unable to act in a manner in accordance with such understanding due to external obstacles (Aitamaa et al., 2010; Corley et al., 2005; Fourie, 2015; Morley et al., 2019, 2020). The concept of moral distress, therefore, can be broadened to include not only the awareness of the right action or measure but also that the action or measure cannot be realized or implemented in a satisfactory manner due to factors beyond a person’s control (Fourie, 2015; Morley et al., 2019; Sandman & Kjellström, 2018). Such factors can include, e.g., power structures, legal constraints, or lack of time (Corley et al., 2005). Moral distress can lead to work-related stress, reduced self-esteem, or negative emotions such as frustration, anxiety, sadness or fear (Corley et al., 2005; Deschenes et al., 2020; Morley et al., 2020; Savel & Munro, 2015). It can also lead to some positive outcomes as professional growth or positive emotions such as improved self-reflection (Deschenes et al., 2020). While it can be considered an ethical phenomenon, where ethical and moral obligations come into conflict, caregivers nonetheless also can experience moral distress without experiencing a sense of conflict (Fourie, 2015; Morley et al., 2019).

A qualitative design was used in the study. The data consisted of texts from interviews with 8 care leaders in an older adult care context. Content analysis according to Graneheim and Lundman (2004) was used to analyse the data. Five themes emerged: (1) moral distress arises from a lack of time, (2) moral distress contributes to a sense of inadequacy but also a sense of responsibility, (3) moral distress arises from an imbalance in values, (4) increased knowledge and open discussion help reduce moral distress and (5) reflection, increased support and increased resources can reduce moral distress.

The purpose of the study was to examine care leaders’ experiences of moral distress in their daily work in older adult care. Moral distress was seen to arise from a lack of time. The participants revealed that they only had time for the most necessary care measures, but that they would like to spend more time patients because doing so would contribute to better-quality and more comprehensive patient care. The participants noted that a lack of time contributed to an inability to provide sufficient mental care for patients and led to the need to prioritize physical work, which negatively affected patients. The COVID-19 pandemic, resulting in among other things increased sick leaves and quarantines, also exacerbated this problem (cf. Vittone & Sotomayor, 2021). For example, certain tasks such as taking patients for outdoors walks had to be deprioritized because of scarce resources (cf. Slettebø et al., 2018). The participants in this study perceived that increased staffing resources could reduce moral distress. They furthermore noted that their moral distress increased when their administrative work was left uncompleted, linked to a lack of staffing resources and the need to assist caregivers by engaging in direct-patient care (cf. Liu et al., 2020). Moral distress was seen to contribute to a sense of inadequacy – but also responsibility. The participants experienced that they were unable to maintain a sense of responsibility for patients to the extent they would like. The participants in this study noted that not only were more staffing resources needed but even highlighted that the type of caregiver was important. Moral distress was experienced when caregivers who are not really interested in older adult care were employed. The participants here also highlighted that moral distress could lead to the development of a stronger sense of responsibility for patients, a positive that could contribute to the desire for “available” staff and greater staffing resources, all to ensure patients’ well-being and experienced sense of security. The participants in this study experienced that their moral distress increased because of the COVID-19 pandemic and ever-stricter pandemic-related guidance (cf. Catania et al., 2020), revealing that caregivers who do not follow pandemic-related guidance could cause them moral distress. This result differs from findings in other studies, where caregivers were instead found to prefer isolating during the COVID-19 pandemic because of their significant fear of becoming infected (Catania et al., 2020).

Moral distress was found to arise from an imbalance in values. Some participants experienced that organizational values linked to patient issues could differ from the values held by those who worked with patients on a daily basis. The experience of consciously doing what one perceives to be incorrect contributes to psycho-emotional damage and damages professionalism (Nasrabadi et al., 2018; Oh & Gastmans, 2015). We found that not only was there an imbalance in values between the organization and the care leaders, but also between the care leaders and their staff. The participants furthermore experienced that it was burdensome when patients’ relatives had a different opinion on a matter than caregivers or the patient. This was linked to the sense that participants were often “caught in the middle”, that they needed to “step on someone’s toes” or that they were required to compromise own values because of the patient’s right to self-determination. Feeling required to fight on a daily basis to protect patients’ rights and right to self-determination contributes to caregivers experiencing a great deal of stress in their everyday work life (Ulrich et.al., 2010). Increased knowledge and open discussion were found to help reduce moral distress. Many participants experienced that a greater awareness of moral distress was needed, because not all caregivers are aware of what it means. The participants emphasized the importance of open discussions about moral distress within an organization (cf. Aitamaa et al., 2019). We found that the participants in this study wanted more training and lectures on moral distress, because it would increase knowledge on the topic (cf. Aitamaa et al., 2016; Aitamaa et al. 2010; Musa et al., 2011) and could lead to personal growth (cf. Oh & Gastmans, 2015). The participants experienced that there was a clear difference between newly graduated caregivers and previous generations regarding their knowledge of ethics, which can be attributed to ethics being more prominent in current nursing education programs. Moreover, in line with previous research (Deschenes et al., 2020; Ulrich et al., 2010), the participants maintained that moral distress would increase over time, in step with increased financial constraints (stricter budgets) and a growing older population, which they linked to an increased need to prioritize tasks and/or other ethical concerns. Reflection, increased support and increased resources can reduce moral distress. We saw that despite encouraging their staff not to do so, the participants ruminated over work matters when not at work. The participants revealed that they sought to compose their thoughts by engaging in hobbies or activities. The participants in this study also noted that time to reflect on current and future work could reduce moral distress; sitting down and engaging in open discussion (and reflecting upon things from different points of views) could increase both own and others’ insights. The participants in this study revealed that they even used different strategies to reduce their experiences of moral distress, e.g., soliloquizing (engaging in self-talk), generally reflecting on the day’s events or therapeutic writing. The participants expressed a desire for support from upper management regarding how to discuss moral distress with their staff. They also wanted upper management to listen to them more and respect their vast knowledge, perceiving that this could lead to reduced moral distress. The participants experienced that the key to reducing moral distress was an open climate, where people could talk about difficult things. Despite perceiving situations characterized by moral distress as being burdensome, the participants still felt that through reflection and discussion they could learn something from such situations and gain new insights and approaches.

Moral distress is something that care leaders, according to this study, experience daily in an older adult care context and it is considered to have increased. Care leaders can experience moral distress from a lack of time; patient-related, relative-related or other ethically difficult situations or an imbalance between own values and an organisation’s, other caregivers’, patients’ and/or patients’ relatives’ values. Increased staffing resources, more knowledge (training and lectures) and time for reflection individually, in groups or with an outside expert could increase care leaders’ insights into and ability to reduce moral distress. Although situations that are characterised by moral distress are burdensome, care leaders have the opportunity to learn from such situations through reflection and discussion and can develop strategies for future ethical challenges.

Moral distress continued to be my research interest in my ongoing doctoral studies. With the doctoral thesis, I wish to bring a deeper understanding of how moral distress is experienced by healthcare workers in the context of older adult care and to examine the role of care leaders and their perceptions of how it could be counteracted and reduced. The objective is also to obtain knowledge about how care leaders can influence moral distress among their staff and how the nurses believe that moral distress could be reduced. The study will be significant in providing an understanding of how care leaders and nurses in the older adult care context experience ethical stress and how they believe that it could be counteracted and reduced. More knowledge about moral distress is needed to be able to counteract and reduce moral distress in the daily work, not least to reduce the risk of burnout and to succeed in keeping the care staff in the profession.

You can find our study in the Scandinavian Journal of Caring Sciences.

Link to the article: https://doi.org/10.1111/scs.13069

Have a great autumn!

Fanny Ahokas


Fanny Ahokas

MSc, RN, PhD student in Health Sciences, Department of Caring Science, Faculty of Education and Welfare Studies, Åbo Akademi University, Vaasa, Finland. Research interests include ethical issues and moral distress within caring contexts.

E-mail: fanny.ahokas@abo.fi 

ORCID: https://orcid.org/0000-0002-2684-9331  

Link to Åbo Akademi University profile: https://research.abo.fi/en/persons/fanny-ahokas

Jessica Hemberg

PhD in Health Sciences, PHN, RN, Associate Professor, Senior Lecturer, Department of Caring Science, Faculty of Education and Welfare Studies, Åbo Akademi University, Vaasa, Finland. Subject leader in pedagogical studies for teachers within Health Sciences Didactics and subject leader for Leadership in Health and Social Care. Research interests include well-being, suffering and loneliness among older adults and young people, as well as leadership, compassion and ethical issues in caring.

E-mail: jessica.hemberg@abo.fi

Link to Åbo Akademi University profile: https://research.abo.fi/en/persons/jessica-hemberg


Aitamaa, E., Leino-Kilpi, H., Iltanen, S. & Suhonen, R. (2016). Ethical problems in nursing management: The views of nurse managers. Nurs Ethics, 23: 646–658.

Aitamaa, E., Leino-Kilpi, H., Puukka, P. & Suohonen, R. (2010). Ethical problems in nursing management: the role of codes of ethics. Nurs Ethics, 17: 469–482.

Aitamaa, E., Suhonen, R., Puukka, P. & Leino-Kilpi, H. (2019). Ethical problems in nursing management–a cross-sectional survey about solving problems. BMC Health Serv Res, 19: 1–11.

Catania, G., Zanini, M., Hayter, M., Timmins, F., Dasso, N., Ottonello, G., Aleo, G., Sasso, L. & Bagnasco, A. (2020). Lessons from Italian front-line nurses’ experiences during the COVID-19 pandemic: A qualitative descriptive study. J Nurs Manag, 29: 404–411.

Corley, M.C., Minick, P., Elswick, R. & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nurs Ethics, 12: 381–390.

Deschenes, S., Gagnon, M., Park, T. & Kunyk, D. (2020). Moral distress: A concept clarification. Nurs Ethics, 27: 1127–1146.

Fourie, C. (2015). Moral distress and moral conflict in clinical ethics. Bioethics, 29: 91–97.

Ganz, F., Wagner, N. & Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nurs Ethics, 22: 43–51.

Graneheim, U. H. & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24: 105–112.

Liu, Q., Luo, D., Haase, J., Guo, Q., Wang, X., Liu, S., Xia, L., Liu, Z., Yang, J. & Yang, BX. (2020). The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health, 8: 790–798.

Miljeteig, I., Forthun, I., Hufthammer, K., Engelund, I., Schanche, E., Schaufel, M. & Husøy Onarheim, K. (2021). Priority-setting dilemmas, moral distress and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway. Nurs Ethics, 28: 66–81.

Morley, G., Bradbury-Jones, C. & Ives, J. (2020). What is ‘moral distress’ in nursing? A feminist empirical bioethics study. Nurs Ethics, 27: 1297–1314.

Morley, G., Ives, J., Bradbury-Jones, C. & Irvine, F. (2019). What is ‘moral distress’? A narrative synthesis of the literature. Nurs Ethics, 26: 646–662.

Musa, M., Harun-Or-Rashid, M. & Sakamoto, J. (2011). Nurse managers’ experience with ethical issues in six government hospitals in Malaysia: A crossectional study. BMC Medical Ethics, 12: 1–7.

Nasrabadi, A., Khoob, M., Cheragh, M., Joolaei, S. & Hedaya, M. (2018). The lived experiences of clinical nurse managers regarding moral distress. The Journal of Medical Ethics and History of Medicine, 11: 1–10.

Oh, Y. & Gastmans, C. (2015). Moral distress experienced by nurses: A quantitative literature review. Nurs Ethics, 22: 15–31.

Sandman, L. & Kjellström S. (2018). Etikboken – Etik för vårdande yrken. Lund: Studentlitteratur.

Savel, R. H. & Munro, C. L. (2015). Moral Distress, Moral Courage. Am J Crit Care, 24: 276–279.

Slettebø, Å., Skaar, R., Brodtkorb, K. & Skisland, A. (2018). Conflicting rationales: leader’s experienced ethical challenges in community health care for older people. Scand J Caring Sci, 32: 645–653.

Ulrich, C., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M. & Grady, C. (2010). Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs, 66: 2510–2519.

Vittone, S. & Sotomayor, C. (2021). Moral Distress Entangled: Patients and Providers in the COVID-19 Era. HEC Forum, 1–9.