Western Journal 10.

1177/0193945905284727 Nathaniel / Moral ofReckoning Nursing Research in Nursing

Moral Reckoning in Nursing

Alvita K. Nathaniel
West Virginia University, Charleston

Western Journal of Nursing Research Volume 28 Number 4 June 2006 419-438 2006 Sage Publications 10.1177/0193945905284727 http://wjn.sagepub.com hosted at http://online.sagepub.com

Analysis of qualitative data resulted in an original substantive grounded theory of moral reckoning in nursing, a three-stage process. After a novice period, the nurse experiences a stage of ease in which there is comfort in the workplace and congruence of internal and external values. Unexpectedly, a situational bind occurs in which the nurses core beliefs come into irreconcilable conflict with external forces. This compels the nurse into the stage of resolution, in which he or she either gives up or makes a stand. The nurse then moves into the stage of reflection in which he or she lives with the consequences and iteratively examines beliefs, values, and actions. The nurse tries to make sense of experiences through remembering, telling the story, and examining conflicts. This study sets the stage for further investigation of moral distress. The theory of moral reckoning challenges nurses to tell their stories, examine conflicts, and participate as partners in moral decision making. Keywords: moral distress; ethics; grounded theory; moral dilemma; decision making

very day nurses are challenged to deal with morally troubling patient care situations. Morally laden questions about right and wrong, harm and benefit, rights and responsibilities are inherent in modern health care. Because they work at arms length from patients, nurses are caught in the vortex of serious moral problems. When nurses moral values conflict with the realities of the workplace, they experience distress, which may linger for many years after the event. Even though scant research exists on this important subject, the concept of moral distress is used often to describe the pain nurses feel during these troubling times. Moral distress is a contributing factor to loss of nurses integrity and dissatisfaction with their work. It also contributes to problems with nurse-patient relationships and thus affects the quality, quantity, and cost of nursing care (Erlen, 2001; Hamric, 2000; Jameton, 1984; Nathaniel, 2004; Wilkinson, 1987-88). The current nursing
Authors Note: The author wishes to acknowledge Dr. Barney Glaser, who served as a mentor for this study.

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shortage affects the delivery of health care services and leads to questions about the future of the profession. Moral distress is a major contributor to nurses leaving their work setting and even the profession. Moral distress, however, is a narrow concept that fails to explain the long-term, ongoing process that nurses experience. The purpose of this article is to present a newly developed grounded theory of moral reckoning in nursing that evolved during research examining nurses experiences with morally troubling patient care situations. This new theory explains more clearly and thoroughly nurses struggles. Moral reckoning is similar to the familiar concept of moral distress but moves further, identifying a critical juncture in nurses lives and better explaining a process with predictable properties and stages. The grounded theory of moral reckoning in nursing is the first to identify a process that includes the stages of ease, resolution, and reflection and to point out workplace deficiencies as a serious moral problem in nursing. Nurses suffer and their lives are forever changed as a direct result of morally troubling patient care situations. Telling their stories emerged as integral to the process of reflecting and as a powerful data-gathering strategy. The theory of moral reckoning also points to a deficiency in nurses knowledge about formal nursing ethics and a need to develop a common moral language among health care professionals.

Moral Distress and Nursing Care

Development of the theory of moral reckoning in nursing began with a review of the extant literature on moral distress, a significant problem in nursing. Although reports of the number of nurses who experience moral distress vary, there is evidence that moral distress is common and may be a contributing factor to the critical shortage of nurses in the workforce. Nearly 50% of nurses in Rushton and Scanlons (1995) study reported that they had acted against their conscience, and Redman and Fry (2000) report that at least one third of nurses in their study experienced moral distress. The immediate and ultimate consequences of moral distress include nurses blaming others; excusing their own actions; self-criticizing; self-blaming; experiencing anger, sarcasm, guilt, remorse, frustration, sadness, withdrawal, avoidance behavior, powerlessness, burnout, betrayal of values, sense of insecurity, low self-worth; internalizing anguish; and, possibly, developing aggressive behavior patterns (Davies et al., 1996; Fenton, 1988; Kelly, 1998; Krishnasamy, 1999; Rushton & Scanlon, 1995; Wilkinson, 1987-88). Physical complaints reported by nurses who experience moral distress include weeping, palpitations, headaches, diarrhea, and sleep problems (Anderson, 1990; Fenton, 1988; Wilkinson, 1987-88).

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The extant literature also indicates that moral distress affects the quality of nursing care. Nurses experiencing moral distress have reported the following behavior toward patients: distancing themselves from patients, becoming emotionally unavailable, avoiding going in patients rooms, and leaving the unit or nursing altogether (Corley, 1995; Davies et al., 1996; Fenton, 1988; Krishnasamy, 1998; Millette, 1994; Redman & Fry, 2000; Viney, 1996; Wilkinson, 1987-88). In all, 50% of Millettes (1994) informants, 12% of Corleys (1995) informants, and 45% of Wilkinsons (1987-88) informants left nursing or changed their practice site as a direct result of moral distress. Thus, moral distress may be a factor in the present nursing shortagea selfperpetuating downward spiral.

Purpose
The purpose of this research was twofold: (a) to further elucidate the experiences and consequences of professional nurses moral distress and (b) to formulate a logical, systematic, and explanatory theory of moral distress and its consequences. This study began with the following broad research question: What transpires in morally laden situations in which nurses experience distress? To allow continued discovery and flexibility of exploration, as is appropriate to grounded theory research, the initial research question was narrowed and redirected as the research progressed.

Definition
The following is a synthesized definition of moral distress as described in previous literature: Moral distress is pain affecting the mind, the body, or relationships that results from a patient care situation in which the nurse is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action, yet, as a result of real or perceived constraints, participates, either by act or omission, in a manner he or she perceives to be morally wrong (Jameton, 1984; Nathaniel, 2004; Wilkinson, 1987-88).

Design
This research utilized qualitative interview data to develop a substantive grounded theory that was developed in strict accordance with the classic method as described by Glaser and Strauss (1967) and subsequently by Glaser (1978, 1996, 1998).

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Sample
The sample consisted of 21 registered nurses, of which 20 were female and 17 were married. Informants were highly educated and experienced: 2 had associate degrees, 3 had bachelors degrees, 13 had masters degrees, and 3 had doctorates. Also, 19 participants were Caucasian, 1 was Hispanic, and 1 was Native American. In addition, 80% had more than 10 years of professional experience, and 43% had left a position because of a morally distressing situation. To ensure the protection of human participants, the proposal for this research was examined and approved by the institutional review board for the protection of human research participants. Informed consent was obtained. Interviews were conducted in private, nonwork settings that afforded privacy to the nurses as they told their stories. The only potential risk identified was psychological distress that might occur during or following the interview. Participants were recruited through various means including an advertisement that was published in a newsletter for nurses, distributed to nurse leaders for sharing with others, and posted at a nurses convention. In the advertisement, nurses were asked to either e-mail or call (toll free) the principle investigator if he or she had ever been involved in a troubling patient care situation that caused distress. Participants were not excluded based on gender or minority status. The target population included all registered nurses who had ever experienced distress in relation to a moral or ethical problem in a patient care situation. All those responding to the advertisement were interviewed until saturation of categories and their properties was reached.

Method
Grounded theory is an inductive method that moves from the systematic collection of data in a substantive area to the development of a multivariate conceptual theory. For this study, interviews were unstructured and casual. An interview method that Glaser (1998) suggests offers an efficient yet meaningful mix of interview, observation, and conceptualization. Interviews were recorded in the form of field notes written immediately after each interview. Because of the sensitive nature of the information and the likelihood that participants would be less likely to share dangerous information, the interviews were not recorded on tape. During interviews, the investigator made brief, contemporaneous notes to ensure that subsequent field notes were factually correct. Field notes were written immediately following the interviews. The constant comparative method was used to gather and com-

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pare data and to conceptualize, analyze, organize, and write the resultant theory.

Analysis of Data
Analysis was simultaneous with other steps of the grounded theory process. It began with the first episode of data gathering. Using constant comparison, data were analyzed sentence by sentence as they were coded. All data were organized into concepts and further into categories that were then integrated into theory. The investigator then went back to the data to illustrate the resultant theory. The focus of analysis was on organizing concepts that emerged from the data. Glaser (1978) calls this a process of double-back steps. The investigator collected research data and immediately began open coding. This led to theoretical sampling and generation of memos. As this process proceeded, core social psychological processes began to emerge, furnishing the foundation for subsequent selective theoretical sampling, coding, and memoing around the identified core category of moral reckoning in nursing. Conceptual memos were written as ideas about categories and processes emerged. Theoretical sampling began when the investigator found categories that required more refinement or areas that needed more depth. As the interviews were coded and compared, moral distress, the original focus of the investigation, failed to emerge as a major category. The core variable, moral reckoning, was identified when it emerged as the one to which all others were related. Analysis of the data revealed that moral distress occurred in nurses who were in the midst of the moral reckoning process. As seen in Figure 1, moral reckoning is much broader, both in temporal and psychosocial spheres, and more explanatory and predictive than is the extant concept of moral distress. As categories became saturated and the relationships among them became clear, the substantive grounded theory of moral reckoning in nursing emerged. Thus, the new theory effectively synthesizes, organizes, and transcends what was previously known. As with each of the widely divergent qualitative methods, grounded theory has its own rules concerning evidence, inference, and verification (Sandelowski, 1986). Glaser (1978) devised terms to describe methods that are unique to classic grounded theory to ensure rigor. These terms, fit, work, relevance, and modifiability, correspond loosely with Lincoln and Gubas (1985) trustworthiness criteria of credibility, transferability, dependability, and confirmability. For the present study, rigor was ensured by fit in that the categories fit the data. No data were forced or selected to fit preconceived or

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Figure 1 The Relationship Between Moral Distress and Moral Reckoning

Situational Bind
Moral Distress

Stage of Ease

Stage of Resolution

Stage of Reflection

Critical Juncture Interrupts Stage of Ease

preexistent categories, nor were any discarded in an attempt to keep an extant theory intact. Thus, the resultant theory is truthful and dependable. Work means that the theory is able to explain what happened, predict what will happen, and interpret what is happening in the substantive areas. This was achieved by getting the facts as perceived by the participants. After the theory was written, feedback from participants and other nurses confirmed the theory. Relevance was achieved as the core problem and processes naturally emerged from the data rather than being preconceived or logically deduced. Modifiability further enhanced the credibility of this grounded theory because subsequent research or analysis can result in modifications or corrections.

Findings
As with other grounded theories, this theory consists of a number of tentative hypotheses derived from the grounded data and written in the form of declarative sentences. The hypotheses are illustrated through case examples. Examples given here are limited to statements of participants, but the theory itself emerged from the interviews and also other forms of data, including the extant literature on moral distress. Early in the study, constant comparison of data revealed that more was transpiring with participants in this study than is described in the extant literature. The definition of moral distress in the literature does not include a theoretically complete picture of the process that occurs. Conflicting with the present findings, the extant definition also includes a requirement that the

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nurse must actually participate in moral wrongdoing, violating his or her own moral values. Mainly restricted to psychological implications, the extant definition of moral distress also implies an us against them mentality in which apparently innocent nurses are opposed by powerful wrongdoers. The stories told by informants in the present study did not entirely fit into the definition of moral distress, so ideas about moral distress constituted merely a jumping-off point for further investigation. As analysis proceeded, the newly identified basic social psychological process of moral reckoning emerged. Figure 1 depicts the theory and its relationship to moral distress. Moral reckoning, the core category of this grounded theory, captures a three-stage process as nurses critically and emotionally reflect on motivations, choices, actions, and consequences of a particularly troubling patient care situation. To reckon is defined as follows:
to recount, relate, narrate, tell; to allege; to calculate, work out, decide the nature or value of; to consider, judge, or estimate by, or as the result of calculation; to consider, think, suppose, be of opinion; to speak or discourse of something; and to render or give an account (of ones conduct, etc.). (Simpson & Weiner, 1989, s.v. Reckon)

As seen in Figure 2, moral reckoning is a process with three distinct stages including the stage of ease, the stage of resolution, and the stage of reflection. Figure 2 depicts the theory with its stages and their properties.

Stage of Ease
After the initial new nurse jitters, nurses experience a stage of ease in which they feel rewarded and fulfilled. Certain properties are foundational to the stage of ease. Integral are the properties of (a) becoming, which signifies core beliefs and values of the individual; (b) professionalizing, which relates to inculcation of the professional norms; (c) institutionalizing, which signifies the process of internalizing institutional social norms; and (d) working, the unique experience of the work of nursing. These conditions are critical to understanding the process. Conflict between and among the conditions work together during a critical incident to produce a situational bind. Becoming. Through the process of becoming, every person develops a set of core beliefs and values. These evolve over time through experience and formal learning and from the modeling of parents, teachers, ministers, and peers. Integration and consistency of core values produce moral integrity (Beauchamp & Childress, 2001). Participants in this study revealed their core beliefs as they told their stories. For example, they talked about a sense

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Figure 2 Model of the Grounded Theory of Moral Reckoning in Nursing

Grounded Theory of Moral Reckoning in Nursing

Stage of Ease

Stage of Resolution

Stage of Reflection
Remembering Telling the Story

Becoming Professionalizing Institutionalizing Working

Giving Up

Taking a Stand Examining Conflicts Situational Bind Interrupts Stage of Ease Living with the Consequences

of responsibility to relieve suffering, a commitment to uphold professional and institutional norms, a duty to advocate for patients, an imperative to keep promises, and so forth. Professionalizing. Professionalizing, another property of the stage of ease, includes inculcation of certain cultural norms learned in nursing school and early practice. Professional norms are conceptual ideals that contribute to the nurses idea of what a good nurse should be or do. For the most part, nurses professional norms complement core beliefs so that the profession and professional norms are uniquely important to the person. Explicitly, nurses in this study learned that they have unique relationships with patients and are responsible to keep promises, which are sometimes implicit in the relationship. They also reported perceived professional norms that include the following nonexclusive, implicit rules: One must follow physicians orders, complete assigned work with expert skill, and remain altruistic. Institutionalizing. Institutionalizing refers to nurses being socialized to implicit and explicit norms within the work setting. Sometimes institutional norms are congruent with nurses core beliefs and professional norms, and sometimes they are not. Explicit institutional norms include completing a job according to institutional standards and respecting lines of authority. Implicit

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institutional norms include ensuring that the business makes a profit, following orders, handling crises without making waves, and covering. As one informant said, Corporate is bigger than life itself. Working. Working is another condition of the stage of ease. Unique in many ways, the work of nursing is varied, challenging, and rewarding. Nurses attend to the most personal and private needs of patients and learn tremendous amounts about their hopes, fears, and desires. They intimately know about suffering patientsfrom touch, sight, smell, and sound. Nurses tell heart-wrenching stories filled with vivid sensual descriptions. Doing the work of nursing includes knowing the patients, witnessing their suffering, accepting the responsibility to care, desiring to do the work well, and knowing what to do. The conditions of becoming, professionalizing, and institutionalizing and the work of nursing are held in fragile balance as nurses enjoy the stage of ease. During the stage of ease, nurses are motivated by core beliefs and values to uphold congruent professional and institutional norms. They are at ease in the workplace, having technical skills and feeling comfortable practicing within the boundaries of self, profession, and institution. They know what is expected of them and experience a sense of flow and feel at home. For example, one informant said,
Early in my career I was employed in the hospital setting and very conscientious about my work. I was very in tune to the patients and their care, wanting to make sure that everything was done that was supposed to be done and that I completed all my work before the next shift came on. I loved the challenge of the medically difficult patient. I always did well in the emergenciesCPR, GI bleeds, chest pains, etc. After those first few months of new nurse jitters, I felt at ease and comfortable at my station.

The stage of ease continues as long as the nurse is fulfilled with the work of nursing and comfortable with the integration of core beliefs and professional and institutional norms. For some, though, a morally troubling event will challenge the integration of core beliefs with professional and institutional norms. Nurses find themselves in situational binds that herald a critical juncture in their professional lives.

Situational Binds
A situational bind interrupts the stage of ease and places the nurse in turmoil when core beliefs and other claims conflict. Situational binds force nurses to make difficult decisions and give rise to critical junctures in their

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lives. Binds involve serious and complex internal conflicts within individuals and tacit or overt conflicts between nurses and others, all having moral or ethical overtones. Inner dialogue leads the nurse to make a critical decision choosing one value or belief over another. Thus, nurses arrive at a critical juncture that compels movement toward resolution and reflection, the remaining stages of moral reckoning. Types of situational binds include (a) conflicts between core values and professional or institutional norms, (b) moral disagreement among decision makers in the face of power imbalance, and (c) workplace deficiencies that cause real or potential harm to patients. These dramatic binds produce significant consequences for nurses and patients. Professional or institutional norms may conflict with core beliefs. Informants explicitly or implicitly alluded to core beliefs as they talked about the struggle to come to terms with conflicts involving professional or institutional norms. For example, one nurse is still troubled because she believes she tortured a patient when she followed orders. The patient had a no code order and experienced extreme discomfort when the nurses performed nasotracheal suctioning. He was alert and made his wishes clear. When he attempted to push away the suctioning tube, the nurse followed physician orders and restrained his arms before suctioning him. In this case, the nurse was in a bind between following procedures sanctioned by the profession and institution (suctioning excess respiratory secretions) and respecting the patients wishes, which seemed to her to be the morally correct action. At one point, she said to herself, This is not what I signed on for. Another nurse wept as she talked about struggling to make sense of the situation when the physician ordered her to administer a potentially lethal dose of medication. On one hand, she had been socialized to believe that nurses should follow physicians orders, yet on the other, her core values included a belief that it is morally wrong to cause the death of another person. The physician wrote the order and went home while the nurse struggled with these conflicting values. She eventually administered the medication, hastening the patients death. Many years later, this nurse still struggles with the conflict between doing what she thought was morally right and following the order, thereby doing what a good nurse would do. Power, particularly asymmetrical power relationships and powerlessness, is a theme that frequently emerges from nurses stories about morally troubling situations. Nurses experience situational binds when they have insight into patients problems yet are powerless in the decision-making process. They feel a strong obligation to respect patients wishes and a desire to affect the appropriate outcome yet often fail in their attempts. Nurses feel that they do not have a voice as they struggle against powerful authorities. For exam-

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ple, several informants experienced powerlessness when physicians and family members made decisions against autonomous patients wishes to perform surgery, insert feeding tubes, perform resuscitation, and so forth. Strongly committed to patient autonomy, the nurses were certain they knew the patients wishes, yet their hands were tied. Even though they did not actively participate in moral wrongdoing (in fact they struggled to prevent it), several nurses in the present study felt guilt and great distress as a result. Power imbalance is also evident when physicians ignore or fail to believe nurses descriptions of deteriorating patient conditions. This is a surprisingly frequent theme. Nurses feel a strong sense of responsibility to patients and take seriously the implicit promise to relieve their suffering. Multiple informants described instances in which on-call physicians refused to come in, refused to order emergency medication, or refused to believe the nurses evaluations of patients conditions. For example, one nurse struggled to have her concerns heard when a middle-aged womans condition deteriorated following a gunshot wound to the neck. The woman died from a simple wound because no one else recognized the urgency of maintaining an open airway, and everyone ignored the nurses appeals. Sometimes nurses perceive themselves to be in binds in the type of asymmetrical power relationships discussed above when there is no frank moral wrongdoing but rather divergent core beliefs. When those with decisionmaking power hold legitimate beliefs that are different from those of the nurse, the nurse believes that moral wrongdoing is occurring. For example, several participants believed that physicians guided families or patients toward decisions consistent with the physicians values, while the nurses beliefs were not considered. In these cases, even though there was no moral wrongdoing that an objective bystander could verify, the nurses felt a great deal of distress. The two types of cases in which this was most dramatic occurred when physicians seemed to lead terminally ill patients or their families toward life sustaining measures or, paradoxically, when physicians suggested that patients be allowed to die. Workplace deficiencies conflict with nurses moral commitments, leading to distress. This places nurses in situational binds because they are unable to uphold their core values. Deficiencies reported by informants included chronic staff shortage, unreasonable institutional expectations, and equipment failure. For example, nurses experience situational binds when they are truly committed to providing care that meets professional and institutional standards yet must care for more patients than they believe is safe. This leads to distress when nurses cannot meet all of their own and others expectations and guilt when they perceive real or potential harm to patients. One nurse in the present study reported that he still feels guilty 20 years after caring for a

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patient who died as a direct result of a laryngoscope that failed during resuscitation attempts. In the midst of the situational bind or soon after, nurses experience consequences such as profound emotions, reactive behaviors, and physical manifestations. Emotions are directed toward the self or others. Informants said they were very torn, bothered horribly, and incredibly sad. They also described feelings of guilt, anger, powerlessness, conflict, depression, outrage, betrayal, and devastation. Physical manifestations included near syncope, crying, sleeplessness, and vomiting. One nurse said she lost sleep for days, another cried for the rest of the shift, and another had crying jags for several days. Behaviors triggered by these emotions included fleeing the unit, ranting and raving, drinking alcohol, and sacrificing self to make it right. Having experienced situational binds in patient care, nurses provide care that may be affected in a number of divergent ways. Subsequent nursing care may be negatively affected, unchanged, or improved. A few informants reported that their nursing care was negatively affected or unaffected. One informant was able to perform only routine tasks at the desk and eventually requested a replacement for the remainder of the shift. Another said even though she had always loved her work, after a troubling incident she resigned because she believed her care would be affected. Most nurses, however, believe that their nursing care improved as a direct result of a situational bind. Some were compelled to make up for what they consider to be wrongdoing by giving more compassionate care, even to the point of sacrificing meals and personal time. One respondent said that the nurses felt compassion for the patient and tried to treat him with dignity and give him better care. Others reported that their care improved in the long term because of lessons they learned in the process. Painful feelings and realizations about harm to patients propels them toward the stage of resolution.

Stage of Resolution
Situational binds constitute crises of intolerable internal conflict. The nurse seeks to resolve the problem. The move to set things right signifies the beginning of the stage of resolution. A critical juncture, this stage often alters professional trajectory. There are two foundational choices in the stage of resolution: making a stand and giving up. These choices are not mutually exclusive. In fact, many nurses give up initially, regroup, and make a stand. Others make an unsuccessful stand and later give up. Making a stand. When confronted with a situational bind, some nurses resolve their distress by claiming their power and making a stand. Making a

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stand takes a variety of forms, all of which include professional risk. Nurses may make a stand by refusing to follow physiciansorders, initiating negotiations, breaking the rules, whistle blowing, becoming activists, and so forth. Several informants made a stand when they refused to follow questionable orders. They refused to help with resuscitation if patients had voiced their objection, to sign coerced surgical consent, and to administer potentially fatal doses of medication. In every instance, another nurse was willing to step in and follow the order. For example, one nurse refused to give a potentially fatal dose of medication to a terminally ill, yet alert, baby who the physicians had decided to remove from the respirator. Another nurse administered the medication, leaving the informant with significant guilt and distress because she had been unable to prevent what she perceived to be harm to the baby. Making a stand is rarely successful in the short term but may occasionally improve the overall situation in the long term when nurses rise above these situations and attempt to make system changes. Nurses also make a stand when they step beyond the customary boundaries of the profession to do what, to them, seems to be morally correct. For example, one nurse had advanced education in pharmacology and was familiar with medication protocols in critical care situations. When she could not reach the physician, she gave a medication she believed was needed to save a patients life, even though performing the action was against professional and institutional norms. Making a stand in this way is risky for the nurse. The actions are sometimes illegal but are commonly successful in the short term. When outcomes are positive, nurses are seldom punished because of congruence with the implicit institutional norms of handling crises without making waves and covering. Making a stand through whistle blowing is also risky. Nurses who whistle blow violate many implicit institutional norms. They are ostracized and subjected to hearings, firing, legal proceedings, and harassment. One informant suffered for many years after whistle blowing. Because of the indignities she suffered, she is under psychiatric care and believes she will never again work as a nurse. Giving up. Sometimes nurses resolve a situational bind by giving up. In general, nurses give up because they recognize the futility of making an overt stand. They are simply not willing to sacrifice themselves to no avail. They may also give up to protect themselves or to seek a way or find a place where they can live with better integration of core beliefs, professional norms, and institutional norms. Giving up includes participating (with regret) in an activity they consider to be morally wrong, leaving the unit or resigning, or leaving the profession altogether. Nurses may seem to give up

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in the short term but move toward preparing themselves for more autonomous roles that allow them to make a stand, on principle, in the future.

Stage of Reflection
Having chosen a course of action in the midst of moral conflict, nurses move from the stage of resolution to the stage of reflection. They remember and reflect as they reckon their actions. The stage of reflection may last a lifetime. The stage of reflection raises questions about prior judgments, particular acts, and the essential self. The properties of the stage of reflection include remembering, telling the story, examining conflicts, and living with consequences. These properties are interrelated and seem to occur in every instance of moral reckoning. Remembering. Remembering is an intriguing property of the stage of reflection. Nurses retain vivid mental pictures of morally troubling patient care situations. These memories evoke emotions many years later. As one nurse said, I dont let go of it. Without being asked, nurses invariably describe sensual memories of the incidentthe sights, sounds, and smells. The images are seared into their minds. Informants said that they can still see the environment in which the situation took place. They remember specific facts about patients such as their names, ages, and diagnoses. After 15 or 20 years, they remember patients faces, exact locations of the patients beds, and sometimes a patients position in bed. One nurse said she could vividly see the emergency department as it looked on that day and for a long time could intermittently smell the odor of burnt flesh that had permeated the unit. In the midst of remembering, nurses experienced evoked emotion even though many years may have passed. Evoked emotions include feelings of guilt and self-blame and lingering sadness, anger, and anxiety. Nurses feel guilt and self-blame even when they did not actually participate in moral wrongdoing. They have guilt related to the patients outcome rather than their own participation in a troubling event. Even when they report a series of events in which they are blamelesssometimes going beyond what is usually expected, trying to rectify a probleminformants blame themselves for bad patient outcomes saying, for example, If I had only called a different doctor . . . or, If I could have made him believe me . . . . Lingering emotional effects are profound for many and include anxiety attacks, crying episodes, depression, and prolonged psychiatric care. Nurses continue to feel anger and to blame those they believe were responsible for wrongdoing. Physicians are most often the target of nurses anger. Other nurses and administrators are also targets of anger and blame. These feelings, harbored for many years, lead to fracturing of professional

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relationships. Referring to a physician who refused to come in during an emergency many years ago, one nurse said, I still have no use for him. Telling the story. Emotions called forth during troubling patient situations linger for many years. The act of telling the story evokes these emotions. Some emotions fade over time, but others linger indefinitely. Remembering is an iterative process. Nurses continue moral reckoning over time, remembering and telling the story as they try to make sense of it. Many informants in the present study wept as they talked about the incidents, yet they desired to tell their stories. All made the initial contact and volunteered to participated in hour-long interviews. At the close of the interviews, most voiced gratitude for the chance to tell their stories. Consistent with the present study, Smith and Liehr (1999) propose that as the person tells the story, he or she gains a full-dimensional, reflective awareness of bodily experiences, thoughts, feelings, emotions, and values. Patterns are recognized, made explicit, and named. Examining conflicts. Telling their stories, nurses examine conflicts in the situation. Nurses struggle as they think about conflicts between personal values and professional ideals. They examine their values and ask themselves questions about what actually happened, who was to blame, and how they might avoid similar situations in the future. As they thoughtfully examine the conflicts, some intellectualize their participation, some set limits, and some gain strength to make a stand and accept the consequences in future situations. As nurses think about their roles in what they consider past moral wrongdoing, some set limits or make pronouncements about their future actions. They may identify a point beyond which they will not again be willing to go. Others vow to take risks to help patients in the future. For example, one nurse talked about taking care of a young woman who was desperately ill. Even though she begged for a cold drink, the nurse withheld fluids because the physician had written an NPO order. After the womans death the next day, the nurse vowed never again to refuse the comfort of a cold drink to a dying patient. Living with consequences. Nurses live with the consequences of a situational bind for a prolonged period of time. No longer comfortable in the original workplace and having fractured professional relationships, nurses may move from one institution to another or from one specialty area to another. They are likely to seek further education, preparing for more autonomous roles or intending to correct the type of moral wrongs they experienced in the

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past. Few informants in this study remain at the bedside, even though most talked about enjoying the work of nursing during the stage of ease. Because all participants in the present study continued to experience evoked emotions when they talked about their experiences, it is possible that the process of moral reckoning may continue indefinitely for some nurses who fail to resolve their feelings.

Discussion
The grounded theory of moral reckoning in nursing is a new and original theory that establishes unique connections, making familiar ideas relevant while giving integrative scope and a new perspective. It is an evocative theory that has the power to inform practitioners and leaders about the realities of the struggle between personal moral convictions and collective decision making. The theory encompasses moral distress but reaches further, identifying a critical juncture in nurses lives and better explaining a process that includes motivation and conflict, resolution, and subsequent reflection. Based on the life experiences of nurses, the grounded theory of moral reckoning in nursing is a powerful new theory that transcends, organizes, and synthesizes the extant literature on moral distress and explains stages of a newly identified basic social process. It also offers important implications for nursing practice, education, and administration and, in the face of a nursing shortage of crisis proportions, presents urgent and unique opportunities for further investigation. The design of this grounded theory research focused on identifying and examining the experiences of nurses who recognized the personal effects of morally troubling patient care situations. Those who volunteered were older and highly educated. The sample did not include nurses who experienced no distress. Perhaps this group had successfully dealt with these types of situations through activism or other strategies. Those who did not recognize or experience inherent conflicts between moral and other claims were also unrepresented in the sample. The grounded theory of moral reckoning in nursing describes only the experiences of those nurses who were motivated to come forward and tell their stories. Further research is needed to describe the experiences of other groups of nurses and compare them to those in the present study. The grounded theory of moral reckoning in nursing points to a chasm between the ethical practice of nurses and formal nursing ethics. This may indicate what MacIntyre (1988) terms an epistemological crisis in nursing, a crisis that occurs when events bring into question ideals and convictions of a tradition and when previous methods of inquiry, conceptualization, and

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principles fall into question. Moral reckoning suggests a need to systematically develop both formal and normative nursing ethics that will serve as accessible tools to nurses in practice, taking into account the situation of nurses in practice and sensitive to both the intricacies of the work of nursing and the primacy of human relationships. Such ethics should allow for consideration of the uniqueness and particularity of each patient and each situation while acknowledging diverse moral perspectives. Nurses should come to understand rival traditions perspectives as different yet complementary understandings of reality. A new ethics of nursing should bind participants in shared symbolism, meaning, and purpose; recognize gender differences while discarding gender and social bias; encompass values of both caring and curing; and refrain from alienating men from women and doctors from nurses. Moral reckoning in nursing suggests a need for enrichment of nursing education. Educators should strengthen nursing ethics education, teach strategies to improve nurses empowerment, model appropriate behaviors, and help students learn effective ways to establish intra- and interprofessional relationships. Educators should closely examine implicit messages transmitted to students, particularly traditions of the discipline that inhibit meaningful dialogue and sustain conflict and power imbalance. They should help students learn strategies and language that prepares them to enter into ethical dialogue with other professionals and prepare them for the realities of dayto-day practice. They should teach students to be ethically self-aware and facilitate dialogue that uncovers sources of conflict among core beliefs, professional traditions, and institutional expectations. They should acknowledge the unique relationship between nurses and patients, recognizing special elements of the relationship such as knowing intimately and witnessing suffering. Moral reckoning in nursing also suggests implications for nurses in practice. Avoiding situational binds and searching for integrity-saving compromise in morally troubling situations may help some nurses to prevent distress and moral reckoning. In an effort to prepare themselves to make cogent and consistent moral judgments, nurses should become familiar with the sociology and history of health care decision making and the basics of moral philosophy. Nurses might purposely examine core values and their relationship to professional and institutional norms. To join the decision-making circle, nurses should learn to appreciate diverse moral perspectives and become fluent in the language of nursing and bioethics. Nurses should also join together to support each other and find ways for experienced nurses to mentor neophytes, exploring conditions that lead to distress and identifying methods to move beyond it.

436 Western Journal of Nursing Research

The grounded theory of moral reckoning in nursing implicates institutional health care as one of the major triggers of moral conflict among nurses. Studies that look at nurses satisfaction and nursing turnover identify many of the same institutional factors as the present research. Synthesizing the existing research on nurse satisfaction, Larrabee et al. (2003) report that nurses are more likely to stay in their work setting when they perceive that they have control of their practice, adequate autonomy, collaboration with physicians, adequate staffing, and organizational empowerment. Negative consequences of high nursing turnover include threats to patient welfare that are posed when institutions operate short of staff or with temporary staffing. Attention should be paid to the relationship between nurses and physicians. Communication and collaboration between nurses and physicians seems to reduce the incidence of nurses moral distress. In turn, the relationships between nurses and physicians are strongly related to patient outcomes (Baggs & Mick, 2000). Baggs and Mick (2000) reported that their findings are consistent with a number of studies done in the past three decades that showed that nurse-physician collaboration has positive correlation with lower than expected mortality, less decline in functional status, fewer acute care days, and fewer readmissions. This suggests that strategies to improve nurse-physician collaboration in the institutional setting have the potential to both prevent nurses moral distress and improve patient outcomes. Nursing administrators need to clearly identify morally worthy goals, examine unit cultures, identify causes of moral distress among nurses, provide support for collaborative decision making, create mechanisms to address abuses, and support nurses and other providers who experience distress. Nurse administrators need to advocate for an ethical corporate culture, which Friedman (1992) proposed should include honorable leadership, protection of and responsiveness to nurses who identify moral problems, encouragement toward ethical achievement, and avoidance of hypocrisy. Administrators should also implement strategies to support nurses who are experiencing distress. As suggested in the recent literature, effective strategies include facilitating dialogue, encouraging nurses to be active participants in clinical and ethical decision making, developing support systems, providing opportunities for professional development, strengthening collaborative teamwork, and identifying and eliminating systematic patterns of dominance and subordination based on gender, race, and ethnicity (Donchin, 2001; Erlen, 2001; Hamric, 2000). Spiraling technology, longer life spans, and higher health care costs in the recent past have contributed to an atmosphere in which nurses are faced with problems of ever-increasing moral complexitysituations in which the most basic moral beliefs about life and death, right and wrong are challenged.

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Moral distress occurs as a result of a dynamic interplay of the nurses moral outlook, commitment to moral principles that may be either intrinsically incompatible or incompatible in specific situations, relationships with patients, role identification, and perception of imbalance of power or other institutional constraints. The newly identified grounded theory of moral reckoning in nursing reaches further than moral distress, identifying a critical juncture in nurses lives and better explaining a process that includes motivation and conflict, resolution, and reflection. In the face of a nursing shortage of crisis proportions, the theory of moral reckoning in nursing presents urgent and unique opportunities for reforms in nursing ethics development, education, practice, and administration and sets the stage for further research.

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Alvita K. Nathaniel, DSN, APRN, BC, is an assistant professor and coordinator of Family Nurse Practitioner Track at the West Virginia University School of Nursing.