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Abstract

Background

Moral suffering is a growing concern in healthcare, especially in the nursing profession. It encompasses various forms, such as moral distress and moral injury, both of which impact nurses’ professional integrity and mental and physical health. Despite extensive research, there is still no consensus on their definitions, distinctions, or causes, which impedes effective interventions. However, given their overlapping characteristics and consequences, joint consideration could offer critical insights to refine existing concepts.

Aim

To explore how nurses in clinical practice perceive moral suffering and analyze the essence of their experience of moral suffering.

Research design

Data were collected through qualitative, semi-structured online interviews. The interview transcripts were analyzed using qualitative content analysis.

Participants and research context

A total of 47 registered nurses from different clinical settings in German hospitals participated in the study.

Ethical considerations

The study protocol was approved by the Institutional Review Board at University Medicine Greifswald. All participants provided written informed consent.

Findings

The essence of moral suffering was determined in five main categories with corresponding subcategories: A trigger situation (1) in which a person in a specific moral disposition is present (2), whereupon they assess the situation as morally meaningful (3) and, accordingly, moral suffering is experienced in its three specific dimensions: (4) the characteristics (dynamic, context-dependence, temporality, fuzziness), dimensions of experience (rational and emotional integrity-related manifestation), and dimensions of action (handling, coping, prevention). This experience of moral suffering has consequences (5).

Conclusions

This study illuminates the complex nature of moral suffering among nurses, revealing its multidimensional essence and the interplay between personal and professional factors. The results underscore the need for a systemic approach to address moral suffering in nursing, emphasizing the importance of ethical leadership and workplace health promotion, and fostering shared values within healthcare teams.

Keywords

moral distress moral injury moral suffering moral integrity moral resilience ethical climate

Introduction

‘Moral suffering’^1,2 is a phenomenon that is receiving increasing attention in different healthcare settings, professions, and positions. It can be described as ‘the anguish that caregivers experience in response to various forms of moral adversity, such as moral harms, wrongs or failures, or unrelieved moral stress, that in some way imperil integrity’.³ Moral suffering is an umbrella term that represents the different qualities of experiencing moral strain. Yet, within the scientific discourse, it mostly refers to specific forms of moral suffering. The most well-known forms are moral distress (MD)⁴ and moral injury (MI),⁵ although moral residue⁶ and moral stress⁷ have also been described as manifestations. However, the definition of each of these different forms of moral suffering (especially for MD and MI) is not agreed upon, and the relationship and distinction between the different forms of moral suffering are still controversial.⁸ The example of MD, which has been criticized as a ‘messy concept’,⁹ can illustrate this. There is disagreement between what can or should be considered as MD in terms of broader and narrower conceptualizations.^10–12 While Andrew Jameton’s initial definition⁴ characterizes MD as arising when a moral actor knows the right course of action but is constrained from acting accordingly, recent definitions proposed by Morley et al.¹³ suggest that MD may also result from experiences of moral uncertainty, tension, dilemmas, and conflict. Furthermore, disagreement prevails about the ethically relevant core of MD,¹⁴ which could be, for example, a negative emotional response and psychological reaction¹⁵ or compromised professional integrity.¹⁶ Oelhafen et al.¹⁷ recently identified two more problems concerning the definition and measurement of MD: the mixing of moral and psychological events and the (often ambiguous or missing) distinction between moral and non-moral events to distinguish MD from other work-related causes of stress. The causes of MD have been researched extensively,¹⁸ and different theoretical models^19–21 as well as empirically grounded models^22–24 have been proposed from various scientific disciplines and through diverse theoretical perspectives (such as feminist ethics, virtue ethics, or psychoneuroimmunology). There have also been calls in the ongoing debate to move away from the discussion about conceptualization and focus, instead, on interventions to combat it.²⁵ The latter, in turn, is difficult, as ‘These challenges [depicted above, author’s note] might undermine the effectiveness of interventions aimed at alleviating moral distress’.¹⁷

Given the numerous controversies about MD, which can similarly be traced for MI,²⁶ it should also be emphasized that there are certain commonalities between these two different forms of moral suffering^22,^27,28; both violate moral integrity^29–31 and provoke strong emotions.³² Furthermore, both have serious effects on mental health, such as burnout,^32–34 depression,^35–37 post-traumatic stress disorder,^32,38,39 and emotional exhaustion.⁴⁰ In addition, the consequences for the profession and the provision of healthcare in general are devastating, as a correlation with the intention to leave the position or profession has been found.^41–44 Thus, there are good reasons to consider the two concepts of MD and MI together because

‘the phenomenal and etiological core attributes of moral injury and moral distress are strikingly similar: intense psychological suffering, such as guilt, shame, anger, and social and spiritual alienation, as a result of something one did, something one failed to do, or something one witnessed that transgressed one‘s moral expectations of oneself, others, or the natural world’.^{45, p.6}

Together, the two are also treated as stages of moral escalation in some cascade/cumulative models^22,^29,32,46,47 and/or ‘on a spectrum of moral trauma’.¹² Attempts to consider them together in empirical studies have already been made by other colleagues, but with different samples than nursing professionals (e.g. social work) and/or in a different context (e.g. COVID-19 pandemic).^48,49

Even if there are a few studies on nurses’ moral suffering (also) using qualitative methods of data collection, they are either only on MI or MD, and stem from another socio-cultural background.^50–52 Qualitative data collection methods on these topics can be found in settings such as home nursing⁵³ or inpatient long-term care⁵⁴ in Germany. A qualitative study with nurses in acute inpatient care in Germany, in which both MD and MI are considered under the concept of moral suffering, has not yet been conducted. However, this is promising in order to critically examine existing theoretical constructs from the perspective of those affected and complete and adjust them where necessary.^{(see e.g.} ⁵⁵⁾

Methods

The report of this study is in concordance with the ‘COREQ (consolidated criteria for reporting qualitative research)’ statement.⁵⁶

Design

The results reported here are part of a larger study within the ‘MoMo’ project (‘Moral Injury and Moral Distress among Nursing Professionals in German Hospitals’, German Clinical Trials Register-ID: DRKS00030785) using a sequential, mixed methods design. Nurses supplied quantitative data within the overall research project aiming to reveal the extent of moral suffering, respectively, MD and MI, with validated instruments (Mai et al., under review), followed by a qualitative sub-study. A qualitative design was chosen to explore the individual experiences and reflections of the study participants⁵⁷ in order to reach a better understanding of moral suffering (especially of MD and MI). In addition, the qualitative findings should explain the observations from the quantitative study heuristically. This material has since been analyzed and is now presented. It has not yet matched the quantitative results (a separate analysis and publication are forthcoming).

Research question

How do nurses in acute inpatient care perceive moral suffering, and what structure (processes, elements) does their experience of moral suffering have? How have they dealt with moral suffering?

Research team and reflexivity

The research team was mixed in terms of gender and degree of qualifications (two undergraduate students, two postdoc researchers, and one professor). All members of the research team are nursing scientists with a professional background as nurses, and one team member holds a doctoral degree in medical ethics.

AHS, TM, and MS have considerable experience in qualitative social research. The research interest resulted from their own experiences in practice and preliminary scientific work on moral suffering and ethical leadership.

Sample, setting and recruitment

Nurses in Germany were informed about the MoMo study and invited to participate through a standardized poster that was distributed via various professional societies and associations (e.g. German Professional Association for Nurses: DBfK) as well as through social media. In addition, federal state hospital associations were contacted. A convenience sample was then obtained from the total sample of those who took part in the quantitative part of the study. Participants were asked on the last page of the questionnaire whether they would be willing to be interviewed. Those interested in the study provided their e-mail address and were sent written information. They could then arrange an interview in a subsequent step using an online booking tool.

Inclusion criteria for the overall MoMo study were (1) qualification as a nurse (vocational training or study programme), (2) active work as a nurse in patient care in a German hospital at the time of the study, and (3) sufficient German language skills.

Ethical considerations

Ethical approval for this study was obtained from the Institutional Review Board of the University Medicine Greifswald, (No.: BB 168/22a). Potential participants were informed about the aims, content, and methods of data collection and analysis, as well as the voluntary nature of participation in a written form. No incentives were provided. Written informed consent was obtained from each participant. The interviewees could ask additional questions at the time of the interview. Participants could withdraw their participation at any time until the data were anonymized during transcription.

Data collection

Data were collected through semi-structured, problem-centred interviews⁵⁸ (Online Supplementary Material I: Interview guide). The interview topic guide was developed based on an extensive literature review and was informed by the above described discourse on different theoretical understandings and conceptualizations of MD and MI as well as on the relationship (or lack thereof) between them. Drawing on these models and available analyses, the interview guide aimed to capture the experiences of moral suffering, perceived differences and degrees of moral suffering, indicators of its occurrence, its impact and strategies for dealing with it.

The interview guide was not followed rigidly but served as a flexible framework to ensure that all relevant topics were addressed in the participants’ narratives. Interviewers used it to prompt follow-up questions when specific themes were not addressed spontaneously.

The interviews were not preceded by a definition of ‘moral suffering’. In their follow-up questions to the interviewees’ narratives, the interviewers took particular attention to focus on the moral dimension of the stress, where necessary, in order to focus the interview on ethically relevant aspects rather than general work-related stressors.

Interviews were conducted by AHS, MS, AS, or RM via videoconferencing. Two interviews were conducted by telephone due to the participants’ technical preferences. Only audio recordings were made during all interviews using an external device. The decision in favour of online interviews was made due to financial resources, while, at the same time, a great diversity of the sample could be achieved, and a large regional reach could be taken into account.

Data analysis

The audio recordings were transcribed verbatim. After a plausibility check, the recordings were deleted, and the anonymized interviews were exported into MAXQDA software for analysis.

After initially familiarizing themselves with the interview transcripts by re-reading them and taking notes, the research team conducted ‘qualitative structuring content analysis’ according to Kuckartz.⁵⁹ This method uses both, deductive and inductive elements. Analysis started with five categories stemming from the interview guide. The team developed a coding guideline (category definition, criteria to distinguish between categories, anchor examples), to enable the consistent assignment to categories across the team. Categories must then prove themselves in practical application during the coding process: Based on line-by-line coding, these were empirically differentiated into subcategories and complemented by further, inductively developed categories that emerged from the data. Text segments that could not be assigned to existing categories were used to inductively form new subcategories. During the further course of the analysis, theories were included^60–62 as ‘sensitizing concepts’ with a heuristic function to support the structuring and interpretation of the data on a deeper level.⁵⁹

Results

Interviews with 47 nurses were conducted between June and August 2023 (Table 1: sample characteristics). The interviews lasted between 17 and 78 min, with an average length of 45 min.

Table 1.

Sample characteristics. *Practical instructors (so called ‘Praxisanleiter’) are nurses who completed further training to supervise nursing students in practice at the bedside. They spend a certain proportion of their working hours with teaching nursing students’ practical skills and assess their progress. They act as a link between theory and practice.

	Nurses (n = 47)
Gender
◦ Male	18
◦ Female	29
Highest qualification
◦ Nursing exam (3 years of vocational training)	12
◦ Specialized training	20
◦ University degree in nursing (Bachelor, Master, Diploma, PhD)	15
Employment
◦ Full time (100 %)	21
◦ Part-time (up to 75 %)	18
◦ Part-time (up to 50 %)	8
Additional qualifications (multiple answers possible)
◦ Palliative care	5
◦ Pain nurse	6
◦ Stroke nurse	3
◦ Oncology	1
◦ Anaesthesia and/or intensive care	16
◦ Psychiatry	1
◦ Clinical ethics consultant	3
◦ Practical instructor*	14
◦ Breastfeeding/Lactation counselling	8
◦ Wound care	3
Working with….
◦ Children	4
◦ Adults	43
Leadership/Management responsibility
◦ Yes	13
◦ No	33
◦ Not indicated	1
Age range (Mean ± SD)	21 – 61 years (40.95 ± 10.3)
Professional experience in nursing range (Mean ± SD)	2 – 40 years (16.59 ± 9.7)

As a result, the basic essence of the experience of moral suffering was determined (Figure 1), which is represented in five main categories with corresponding subcategories (Table 2: overview of categories and subcategories): A trigger situation (1) in which a person in a specific moral disposition is present (2), whereupon they assess the situation as morally meaningful (3) and, accordingly, moral suffering is experienced in its specific essence and phenomenality – dimensions of moral suffering – (4), which leads to consequences (5).

Figure 1.

Essence of moral suffering.

Table 2.

Overview of categories and subcategories.

Category	Subcategory
Triggers	Macro level
	Professional policy
	System failure
	Framework conditions enforce prioritization and implicit rationing
	Advances in medical technology
	Meso level
	Discrepancies in professional understanding
	Patient’s wishes
	Over-therapy
	Poor interdisciplinary and interprofessional cooperation
	Strict hierarchy
	Micro level ( intra- personal )
	Lack of self-efficacy
	Lack of professionalism among colleagues
	Fear
Moral disposition	Professional moral standards
	Personal normative guidelines
	Character/Personality
	Life experience
	Work experience
	Stress in one’s personal (private) environment
Moral meaningful situation	Lack of person-centred approach
	Professional overload
	Extreme situations
Dimensions of moral suffering	Characteristics
	Dynamic
	Context-dependence
	Temporality
	Fuzziness
	Dimensions of experience
	Rational integrity-related manifestation
	Emotional integrity-related manifestation
	Dimensions of action
	Handling
	Coping
	Prevention
Consequences	Career reorientation
	Change of field of activity
	Change of employer
	Reduction in working hours/part-time work
	Further training/qualifications
	Changing perceptions of the profession
	Changing social life

Given the complexity of the findings, it is not feasible to present all of the categories in detail. Therefore, only selected illustrative examples are provided, with particular emphasis on the dimensions of the moral suffering.

Triggers

Interviewees described several triggers as necessary conditions for the subsequent moral suffering. These triggers reveal the circumstances that lead to moral suffering and its main causes. Medical-technological progress, healthcare policy, and framework conditions dictating prioritization and implicit rationing are triggering factors at the macro level.

‘It’s not wholly my fault that some things are the way they are; it’s just a systemic problem. That‘s why I can create a bit of distance for myself by saying, “Okay, I didn’t act the way I believe is right, but I was externally forced to do so.”’ (05RM)

‘It’s […] a certain feeling of powerlessness. I’m at a point now where I’ve done everything I can, but the system is actually failing. Whether that’s the social system, the healthcare system […] This system, when it somehow stops working. When your hands are tied and you can’t continue’. (03RM)

The discrepant professional understandings expressed by the actors at the meso-level represent a significant triggering factor.

‘It’s this, how should I put it, lack of emotion, indifference in the context of care, for example when someone is being washed. Or situations in conversations, for example. It’s often the case that I think to myself, hey, how are you talking to the patients? That’s not right. […] It’s morally wrong, for example, to shout at old people when they’re delirious. You just can’t do that, it’s not right. And I have to say that I’m seeing more and more of this in nursing care […] this moral sense is somehow only rudimentary now’. (17AHS)

Further factors relate to the patient’s will (which is either unclear, not taken into account, acted upon in contradiction, or not reassessed during the course of treatment), overtreatment, hierarchical structures and decisions, and a lack of interprofessional cooperation.

‘Treatment measures and nursing procedures that go against the patient’s wishes, aggressively prolong life and prevent death are moral dilemmas’. (13AHS)

A lack of self-efficacy was expressed on the intra-personal level.

‘The fact that you are particularly burdened morally as a caregiver, who is then kind of caught between a rock and a hard place; whether it is still ethically correct, but you only have limited influence’. (20AHS)

Moral disposition

A nurse’s moral disposition comprises individual factors that modify the experience of moral suffering and includes both personal and professional aspects, which are inextricably intertwined. It includes the professional ethos, allowing emotions (as a prerequisite for a flourishing professional self-identity), understanding nursing as a profession (as opposed to a mere ‘job’) and/or a vocation, as well as the aspiration for good care and the goals of professional action. Empathizing is described as pivotal in this regard: Questioning oneself ‘what would I need in this situation if I were the patient?’ is used to determine what is morally burdensome in a given circumstance.

‘Personally, when I imagine myself as a patient, I wouldn’t want certain things either. […] Things that aren’t really necessary. You can discuss everything somehow or do it later, or just take your time’. (21AHS)

Another key component is personal normative orientation, which is understood as a set of values. This includes professional socialization, which is shaped by age, with younger generations often described as more attuned to the moral dimensions of a situation and placing higher expectations for support. Moreover, it encompasses aspects of the individual nurse’s character or personality, including a pronounced sense of justice, perfectionism, idealism, and a self-conception as a ‘moral authority’.

‘I always say that I have a moral compass, so I make sure that everything I do is somehow in line with morality and justice […] I have a very strong sense of justice. And that’s why I notice that many people don’t have that’. (17AHS)

Both professional and life experiences, which may serve as protective factors, shape the moral disposition. The former can have a positive or negative effect, while the latter is described as a protective factor.

‘So having more experience of this kind in your professional life does not necessarily make it easier. In fact, it can lead to what I observe in many colleagues, they become numb. (...) The more experience of this kind that is not worked through, the more numb colleagues become. I think that professional experience and personal experiences from your private life must also be taken into account. And that plays a big role for me. I believe that life experience is a good protective factor in itself, because someone who is 50 years old can naturally deal with it differently than someone who is standing at a bedside for the first time after completing their training and keeping a young woman alive because she is an organ donor’. (11AHS)

‘Yes, I think professional experience, the fact that you’ve seen so much and so many different fates, and perhaps also life experience, makes you realise at some point that you can’t take on everything that isn’t good for you’. (19AHS)

Additionally, stressors in one’s personal environment, such as caregiving responsibilities or challenges related to children and family, can further modulate the moral disposition.

‘I think that even when you can’t fully carry out nursing duties – like, when you can’t completely take care of the ‘basic things’ – that’s already a moral problem or a morally distressing situation. But it’s so common. (…) For example, my grandmother is in a nursing home, and I’m very involved there. I visit her almost every day, and even there I see that nursing tasks aren’t done regularly. And that really bothers me. So, when I go to work, I do it with the intention or with the expectation of myself and my work, that the things that upset me about my grandmother’s care are things I don’t want to repeat in my own work’. (03RM)

Moral meaningful situation

Interviewees described the thematic content of morally meaningful situations, starting from their individual moral disposition (i.e. the nurses moral constitution shaped their perceptions of what was morally meaningful). Several agents can interact in these situations, and moral suffering may arise in different ways. It can result from interactions between agents, from observing the behaviour or competences of colleagues, or from the high clinical demands of specific situations (e.g. prioritization, resuscitation, or requests for assisted suicide) that challenge one’s own moral integrity. Both lead to the perception of not being able to live up to one’s own standards in terms of person-centredness and ‘good nursing care’. The lack of person-centredness was described as both a trigger (category 1) and the subject of the morally meaningful situations themselves.

‘My goal is to do a good job. And I know what I can achieve with care. I have additional training and I’m good at what I do, but I’m not given the opportunity to do it because we are so understaffed’. (09AHS)

Consequently, the quality of care was rated as poor.

‘Colleagues who have language barriers or who just carry out “business as usual.” That makes them feel secure, but then they don’t provide other tasks. They don’t reposition patients regularly, they don’t mobilise them. They do not perform oral care just because the patient refused it once; but they don’t ask again. And then you come to shift and think: So poorly cared for. (...) And then there’s also the medical aspect, the lack of beds and not having enough time’. (02MS)

Dimensions of moral suffering

The interviewees expressed four characteristics of moral suffering (context-dependence, dynamics, temporality, and fuzziness), two dimensions of experience (rational and emotional integrity-related manifestation), and three dimensions of action (handling, coping, and prevention).

Characteristics of Moral Suffering

Context-dependence refers to the interdependent relationship between nurses and patients, where the characteristics of both parties influence the emergence and intensity of moral suffering. Nurses describe how patients’ conditions, characteristics (e.g. disease, age, relationship), behaviours, or vulnerabilities can evoke moral suffering, while their own professional roles and responsibilities shape how they respond to such situations.

‘Well, of course there are differences [in experiencing moral suffering]. For example, we have a mother who has two children with childhood dementia. The disease itself is already super, super rare, and she has two children with it. And you really ask yourself, how can one cope with that? (…) that affects me even more than, let’s say, when I have a family where I know they still have two other children and can see how beautiful life actually can be. Whereas a mother who just gave birth to two boys is now burdened with such a fate’. (19AHS)

The dynamics of moral suffering are determined by factors that either worsen or mitigate its severity. Nurses describe these dynamics as fluctuating according to personal, professional, and situational circumstances. Correlations between private and professional experiences also play a role, leading to increase, decrease, or stability in moral suffering.

‘I experience it differently from situation to situation […] There are also personal factors to consider. My own performance. Have I slept enough? Is everything nice privately? […] Therefore, various factors merge into one another. Those that I can control, but also those that I can’t control’. (11AHS)

Temporality means that moral suffering can be realized not only during but also only after a lived experience or an event.

‘I often only recognise this moral distress when I talk to certain people about it or reflect on it afterwards. At first, I may not recognise it and only notice that something is wrong in the situation. But at that moment, it doesn't really affect me that much. However, it is all the more striking to notice it afterwards and then deal with it’. (18AHS)

‘While it’s happening, you often already feel a bit uncomfortable in the situation, but real reflection usually comes afterwards. In the moment, you’re just acting on autopilot. You have to get through your shift somehow. It’s not as if you can focus on just one problem; you have to keep going. Later, you might realize that you didn’t respond the way you would have liked to, because you were so stressed that you couldn’t give everyone the attention and care they deserved. And yes, it often happens that at the end of your shift, you think to yourself, “I didn’t really live up to the standards I set for myself. And then there is the moral distress.”’ (03AHS)

Fuzziness refers to the blurring of moral suffering, as opposed to other forms of stress in everyday nursing care (e.g. work-related stress). The interviewees’ descriptions show, that it is not always entirely clear to them where moral suffering begins, or whether their experience might relate to another form of work-related strain.

‘I don’t know if it’s this moral stress. In any case, it’s personal stress for me’. (AHS22)

‘Maybe it’s all kind of connected. Yeah, I mean, workload, morally you’d have to speak about it at some point. So maybe it’s both, or I’m mixing the two up. Or maybe they just sort of blend into each other. I don’t really know’. (26AHS)

‘Burnout is really nothing more than the accumulation of morally burdening situations. If I have burnout, then I have been experiencing too much moral suffering’. (13AHS)

Dimensions of experience

Concerning the dimensions of experience, the emotional integrity-related manifestations range from an undefined, non-specific feeling of tension, stress, and dissatisfaction to fear, anxiety, sadness, disappointment, powerlessness, and the associated frustration and/or anger. Inner turmoil and feelings of guilt were also described. Rational integrity-related manifestations are expressed as discrepancies in values, such as between autonomy and care, the need for care and affordable support, and nurses’ own values and expertise versus the ‘official’ diagnosis. The discrepancy between their professional experience and intuition on the one hand, and the situational demands that prevent them from acting in immediate accordance with these on the other hand, results in a moral dilemma for them.

‘When there are already signs that this patient is hypoxic, but the diagnostics simply do not show it. I find these things very difficult because you just know from years of experience that it is no longer compatible with life, but the diagnostics simply cannot be carried out yet’. (04AS).

Other manifestations include questioning the meaning or recognizing the futility of medical procedures, a violated sense of justice, and conflicts of conscience, as well as intra-personal role conflicts (i.e. different and conflicting responsibilities as a nurse manager and bedside nurse at the same time). It is also specific to the experience of moral suffering that professional and personal roles cannot be separated.

‘Well, I think that you encounter many stressful situations, especially in an intensive care unit, but you have to keep functioning. And I would also say that I am very good at separating the two. But when it comes to moral stress, I find it very difficult to separate it from myself mentally’. (20AHS)

Dimensions of action

Three dimensions of action (handling during the event, coping in the aftermath, and prevention for the future) were described to deal with moral suffering. During the event, nurses reported strategies such as allowing emotions, seeking reassurance from colleagues regarding their assessment of the situation, and showing moral courage by upholding and defending their own values and beliefs. In the aftermath, key coping strategies included self-reflection, taking distance from everyday work, and discussing the experience with team members. Prerequisites for the latter strategy – which was regarded by nearly all interview participants as the most important one – include knowing that these colleagues are themselves familiar with experiences of moral suffering, that they share a good interpersonal relationship, that they hold similar moral values, and a safe space to talk or at least a quiet moment.

‘Most of the time I talk about it with people where I feel they’re open to it. Those who are also morally affected by the situation, who witnessed it, and who, for example, share my decisions or feel morally burdened, too. And usually, those are colleagues who would also like to change something about it. So, when I think about it now, I realize I mostly talk to colleagues who actually want to change things, too. People who, for instance, take it seriously within the team, who don’t want to keep working like this forever, who really see that it’s not good in the long run to just accept it, tick it off, and blindly keep going’. (20AHS)

The limitations of these collegial conversations become apparent when they turn into complaining without consequence (which is particularly in cases of deeper, structural problems), when relief fails to occur because the experience was too severe, when colleagues have become numb and no longer wish to engage with moral questions, or when colleagues are themselves so morally burdened that they cannot or do not want to hear about another nurses moral suffering.

‘Our team – we’re about 60 nurses – and you can imagine that there are also colleagues who just do their job according to the schedule. (…) I don’t need to talk with them about moral suffering, or a difficult decision because I already know what’s coming. They’ve kind of become numb. And that just doesn’t help me in those moments. When I want to talk to someone about it, I need someone who’s supportive, who doesn’t play it down, and who maybe has some advice or something to say that makes it all feel a bit less heavy’. (10AHS)

‘Well, I think that talking with colleagues can sometimes lead you to get stuck in this kind of complaining mode. And I know for myself that I’m really prone to that – it happens to me again and again – so I try to be careful, because I actually find it completely useless. I mean, spending three quarters of an hour on a break with a colleague, venting about everything, sure, it’s a bit of a relief in the moment, but it doesn’t really get us anywhere’. (16AHS)

‘I talked about it with the team, because it really left me completely stunned, and I definitely took it home with me – it weighed on me so much. I also felt partly to blame, because I was the one carrying out those measures, or at least I was there and couldn’t stop it. And that’s when I realized that just talking about it isn’t enough for me. It gives me a bit of relief, but only for a short time. It’s just not enough to really get those thoughts out of my head, the anger, and also the guilt’. (20AHS)

For prevention, nurses identified influencing factors across several levels – society, the nursing profession, the institution or organization, management, teams, and the individual nurse. Preventive measures were seen as opportunities to positively influence similar situations in the future, often supported by the learning effects gained from managing morally challenging experiences.

According to the interviewees, it is essential for each of these dimensions of action that they feel seen and understood by their leaders and receive proactive offers for support.

‘Well-trained leaders […] So of course you can’t change the staffing situation and perhaps you can’t give employees more money or a pay rise or something like that. […] But I believe that if you have a strong leader who is not only technically competent, but also has leadership skills, in the sense of how do I communicate with my employees, how do I value my employees? How attentive am I, how do I deal with certain situations and mistakes? And how do I challenge my employees? Then I think I can simply create a good little framework, at least for my own team’. (03RM)

Consequences

A major consequence of moral suffering was considering leaving the profession, changing the field of practice, or pursuing further training or/and qualifications.

‘I can handle all the work. But I can’t handle always having to leave with a guilty conscience. And that’s what I often hear from colleagues who are leaving the profession. I am no longer able to live with this guilty conscience. I can’t take it anymore. And that’s why people are leaving’. (09AHS)

A shift in the interviewees’ understanding of the profession, characterized by a diminished emphasis on person-centredness and a loss of elements previously regarded as fundamental to their professional identity, represents an additional consequence. Moreover, resignation, blunting, and physical and psychological impairments (e.g. sleep quality, illness), changes in their social life (e.g. neglect of their private life and social contacts), and a tendency to make mistakes were described.

Discussion

Our study confirms previous study results regarding the triggers,^63,64 topics in moral meaningful situations,^64,65 and consequences^35,66 of experiencing moral suffering, thus, emphasizing the importance of the problem, as shown in international studies.⁶⁷

New findings from our study that need to be given greater consideration in the future include the following: firstly, the mutual dependency of the private situation and professional role regarding moral suffering. This interconnectedness appears to be a key mechanism shaping the overall experience of moral suffering among nurses and may serve as a crucial entry point for interventions. Consequently, it should, for example, lead to the private situation being considered within the concept of ethical leadership and occupational health management assessing nurses’ moral suffering.^68,69 However, in order to ensure ethical legitimacy and respect for personal boundaries of such an holistic approach, transparent communication (i.e. openness about what personal information is being considered, why, and how the information will be used), a clearly articulated conceptual framework of workplace health promotion, and the explicit consent of the nurses respecting their autonomy and privacy, is required. Assessment instruments designed for dialogue that serve to capture moral suffering and, simultaneously, allow for reflection and dealing with it seem promising but require professional guidance and support.⁷⁰ Overall, the focus should not be limited to moral suffering but also on nurses’ strengths and resources. Rushton’s Moral Resilience Scale, which can be used to assess responses to moral adversity, personal integrity, moral efficacy, and relational integrity in clinical practice, is a good example here.⁷¹ The results of the self-assessment – for example, in the context of clinical ethics work and/or the activities and proactive support services of clinical nurse ethicists^72,73 – can serve as a basis for identifying or developing tailored approaches for individual nurses.

Secondly, professional experience also shapes moral suffering – a result that other studies have also come to.^74,75 Interestingly, according to our interviewees, more years of professional experience can both increase and decrease moral suffering. Further research is, therefore, needed to determine when and how professional experience acts as a promoting or hindering factor for moral resilience, that is, for ‘the capacity to preserve or restore integrity in response to moral adversity’.^{3, (p. 125)}

Thirdly, although the most common strategy described for dealing with moral suffering is discussion with colleagues (a finding confirmed by recent research⁷⁶), such discussions are considered very different in terms of their usefulness. Thus, it appears that factors other than the strategy itself influence if nurses achieve their desired outcomes of relief and support. Shared values are crucial for determining whether this ‘best practice’ is effective: when colleagues share a common understanding of good nursing care and agree on the values, the approach can be beneficial; without it, such conversations tend to be perceived as unhelpful. This result emphasizes the importance of shared values and a good ethical climate.⁷⁷ Furthermore, it aligns with the view that integrity is relational in nature; rooted in relationships with others and shaped through interaction with them.⁷⁸ Consequently, this also implies that – as suggested in other models – more attention should be paid to team dynamics and epistemic injustices as compounding factors.²² Integrity can only be safeguarded where the ethical climate allows and encourages moral agency to be exercised. This, in turn, offers a developmental perspective on moral suffering, emphasizing the promotion of moral resilience through constructive engagement with differing moral viewpoints within the team.

The fourth key finding is the fuzziness of moral suffering itself. The interviewees’ descriptions revealed that they had a broad understanding of moral events and moral suffering. From a methodological perspective, we might have counteracted this by providing a definition at the beginning of the interview. However, it can be assumed that, based on their training and further education, nurses already have a preliminary understanding of moral suffering. Furthermore, due to the lack of a standardized, generally accepted definition of MD and MI, this problem cannot be fully solved, but may merely shift it to another point in the research process as we could have used a very broad or narrow definition, as discussed in the context of MD.^10,79,80 The theoretical debate about the lack of specificity of the concept of MD and the question of what already, still, or no longer counts as ‘moral’ is reflected here in practice.¹⁷ Moral suffering often arises at the intersection of different work-related challenges. In practice, the boundary between moral suffering and general work-related stress seems to be often blurred, finally occupational stressors such as staff shortages can themselves give rise to moral suffering. Thus, they are interdependent and might share common sources in some cases, even if they differ in nature. Rather than attempting to eliminate this conceptual ambiguity it should be acknowledged that it reflects the complexity of moral suffering in nursing practice. This insight calls for sensitivity to the diverse ways in which nurses experience and ‘label’ moral suffering, ensuring that support and interventions are inclusive. For clinical ethics, this finding suggests the need to address issues that may not initially present themselves as ethical problems in the narrow sense. Furthermore, they should engage in close collaboration with related areas such as patient safety, error management, quality assurance, and staff representation to ensure a comprehensive and supportive approach to alleviate moral suffering and to protect and/or restore integrity.

The last point worth looking at is the strategy of ‘empathizing’ described earlier, which appears to be scarcely reflected on. On the one hand, it is described as a strategy to maintain or even increase person-centredness in the face of moral suffering. On the other hand, there may be a danger of losing sight of horizons of interpretation other than personal ones, meaning that empathizing can also pose a threat to professionalism and objectivity. If self-reflection is missing, the strategy can undermine the goal of person-centredness. However, how can such a reflection succeed, and on the basis of which criteria can it be carried out? Reflecting on what one would want in a given situation while actually not being in that situation seems to conflict with the ethical task of exploring what the patient (or their surrogate) would want and what values are underlying those wishes. On the other hand, this fits in with the understanding that integrity is relational.

Conclusions

This study provides insights into the experiences and essence of moral suffering among nurses. The dimensions of moral suffering encompass context-dependence, dynamics, temporality, and fuzziness, with both rational and emotional manifestations. The key findings highlight the interconnectedness of personal and professional aspects in shaping moral suffering, the varied impact of professional experience, the importance of shared values in coping strategies, and the inherent fuzziness of the concept itself.

These results highlight the need for a more comprehensive approach to addressing moral suffering in nursing – one that is embedded within a broader overall concept of workplace health promotion. Such an approach should recognize how organizational structures, ethical leadership, and nurses’ personal factors (such as private circumstances, personality, and preferences) are intertwined and collectively contribute to workplace well-being.

The results also reinforce the moral resilience model. Future research should focus on clarifying the role of professional experience in moral resilience and exploring effective strategies for fostering shared values and a positive ethical climate within teams. Additionally, further investigation is needed to refine the conceptualization and measurement of moral suffering, given its complex and multifaceted nature.

Footnotes

Acknowledgements

We thank Susanne Berger for creating the Figure 1.

ORCID iDs

Anna-Henrikje Seidlein

Tobias Mai

Consent to participate

Written informed consent was obtained from each participant before the interview.

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This work was supported by a grant from the Goethe-Corona Fond of the Goethe University Frankfurt.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data Availability Statement

The data generated and analyzed during the current study are available from the corresponding author upon reasonable request. *

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