Guest editorial

It has been approximately 30 years since Andrew Jameton coined the term moral distress to describe the challenges and emotions nurses experience when they face constraints while attempting to act on what they believe to be right. Since that time, much has been published about the moral distress of not only nurses but also of other healthcare professionals. This special edition of Nursing Ethics marks this milestone by bringing together a number of excellent manuscripts that further this scholarship by examining the relationship of moral distress to a host of important variables in the work lives of nurses, expanding the international focus of the research, synthesizing existing papers, proposing interventions to prevent and lessen moral distress, and debating the future and relevance of moral distress as a concept. Through my involvement with this edition, I have had the opportunity to reflect on a great deal of scholarly work on moral distress and to consider why it has had such widespread appeal in nursing ethics and to contemplate what future efforts in the area should be. A recent retrospective by Jameton explains the origins of the concept in a way that provides insight into how it should evolve in the future. He describes how nursing students in the 1970s and 1980s tended not to express their ethical concerns as dilemmas that could be examined through the use of basic ethical principles, but instead tended to focus on issues regarding the ‘‘dilemmas of institutional life’’ (p. 298), such as those concerning relationships, conflict, power, loyalty, and assertiveness. These students, who were often in close emotional and physical proximity to patients, also spoke of the distress they experienced as a result of their witnessing of patient suffering. This positioning of nurses with respect to the institution and patients thus became the wellspring for the concept of moral distress. It may be that moral distress has made the social–moral space of nursing expressible in a way that many other concepts have not, with moral distress acting as a window through which nurses can identify and describe the ethical nuances of their experiences. The problem may be, however, that we have asked too much of this concept by attempting to articulate more about the nature of nurses’ ethical lives than it can reliably hold which has led to confusion regarding the meaning of moral distress and an over-emphasis on nurses’ weaknesses as opposed to their strengths. My first recommendation, therefore, is that we also highlight alternative concepts in nursing ethics or develop, adapt, or borrow new ones that speak to the social–moral space of nurses. It is not that moral distress is no longer relevant, but we need to expand our understanding through additional concepts that help us understand the ethics of nursing work with its frequent proximity to patients or clients and its political positioning in a variety of settings. After all, the social–moral space of nurses does not just generate distress; it also opens opportunities to improve the well-being of patients because nurses are often in the position to provide and coordinate care in a way that recognizes patients as unique people.