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Running head: MORAL RECKONING IN NURSING1

Moral Reckoning in Nursing Theory Critique

Tamara Mohr, RN

Ferris State University


Moral Reckoning in Nursing Theory Critique

Moral distress is a major contributor to nurses leaving not only their work settings, but

also to leaving the nursing profession altogether. In today’s healthcare environment, the

combination of ever-changing technology, longer life spans, power imbalances, and budget

restraints creates an atmosphere where moral dilemmas are more complex and common than

ever (Nathaniel, 2003). The theory of moral reckoning in nursing was developed by Alvita

Nathaniel in 2003 as an attempt to explain, in a more in-depth manner than they had been in the

past, the moral dilemmas nurses struggle with. This critique will attempt to explain moral

reckoning, as well as look at what causes moral distress in nursing practice, the stages that nurses

go through when dealing with this issue, and how employing this theory may ultimately help to

reduce the incidence of nurses leaving their chosen profession.

Description and Concepts

Moral reckoning and moral distress in nursing are similar concepts, as both include a

troubling event which challenges the nurses’ core beliefs and contains consequences for their

actions, forcing them into a critical juncture in their nursing practice (Nathaniel, 2008). Moral

distress was first described in 1984 by Andrew Jameton, a philosopher and ethicist, after

interviewing nurses about moral dilemmas they had faced. The nurses talked about being in

situations in which they felt helpless to follow a course of action that they felt was morally

correct (Nathaniel, 2003). This led Jameton to state that “moral distress arises when one knows

the right thing to do, but institutional constraints make it nearly impossible to pursue the right

course of action” (Jameton, 1984). Jameton concluded that nurses felt compelled to share their


stories due to their profound suffering, and their belief in the importance of these situations

(Jameton, 1984).

In comparison, the term reckoning is explained as the action of explaining to another an

account of one’s conduct, and avenging or punishing of past mistakes. Employing this

terminology, moral reckoning is the culmination of nurses’ reflection on their motivations,

choices, actions, and consequences in relation to a particularly troubling patient care issue.

Therefore, the theory of moral reckoning attempts to go beyond moral distress by identifying this

critical juncture in nurses’ lives, and explains moral reckoning as a process that has predictable

properties and stages (Nathaniel, 2006).

Nathaniel decided to delve further into the concept of moral distress after co-authoring a

book on ethics. The purpose of developing the theory of moral reckoning was two-fold.

Nathaniel wanted to further explain the experiences and consequences of nurses’ moral distress,

and also desired to formulate a theory of moral distress and its consequences in a manner that

was logical, systematic, and explanatory (Nathaniel, 2006). Development of this theory began

with a literature review on nursing ethics, empowerment, and moral distress. For inclusion into

her research, studies needed to identify moral distress as either a finding or the purpose of their

research, and the subjects needed to be nurses who provided direct patient care. Using these

guidelines, Nathaniel (2003) found there were only 18 published studies that fit these criteria,

and of those, only four identified moral distress as their purpose.

Following this literature review, interviews were conducted using a classic grounded

theory method using nurses who had reported having morally distressing patient care

experiences. These interviews were unstructured and casual, and Nathaniel employed a mix of


interview, observation, and conceptualization (Nathaniel, 2006). The sample consisted of 21

registered nurses who were highly educated and experienced. Of these nurses, 80% had more

than ten years of professional experience, and 43% had left their position due to a morally

distressing situation (Nathaniel, 2006).

Through this process, four concepts began to emerge: ease, situational binds, resolution,

and reflection (Nathaniel, 2008). The stage of ease is experienced after the initial novice nurses’

anxieties disappear. During this time, nurses feel rewarded and fulfilled, and enjoy a sense of

satisfaction in their workplace. According to Nathaniel (2006), characteristics that are essential

in this stage are (a) becoming, which signifies core beliefs and values; (b) professionalizing,

which relates to cultivating professional norms, (c) institutionalizing, the process of internalizing

the institution’s social norms, and (d) working, the unique experience of the nursing profession.

As long nurses are fulfilled in their work and are integrating their core beliefs and professional

and institutional norms, they will continue in the stage of ease. However, according to Nathaniel

(2008), for some a morally troubling event will occur, and this situational bind will bring them to

a critical juncture in their professional life.

Situational binds terminate the stage of ease and force nurses into the resolution stage.

There are three types of situational binds, which are conflicts between core values and

institutional or professional norms, moral disagreement between decision makers in the face of a

power imbalance, and workplace deficiencies which cause real or potential harm to patients

(Nathaniel, 2008). When nurses are faced with situational binds, they are forced to choose one

value or belief over another. Nursing care may become affected, either positively or negatively.

Some nurses are unable to ever return to their unit, whereas for others, patient care improves due


to lessons learned in the process. The painful feelings and realizations about harm to patients

propel nurses to the stage of resolution (Nathaniel, 2006).

The move to make things right constitutes the beginning of the stage of resolution.

Nurses have two choices at this point, which are making a stand or giving up (Nathaniel, 2006).

Making a stand can take a variety of forms, such as refusing to follow physicians’ orders,

initiating negotiations, breaking the rules, whistle blowing, or becoming activists, all of which

involve taking a professional risk. Making a stand is rarely successful in the short term, but may

eventually result in overall improvements in the long term. When nurses decide to give up, it is

generally because they recognize the futility of making a stand and are not willing to pointlessly

sacrifice themselves (Nathaniel, 2006). Some nurses may give up in the short term but

ultimately move toward preparing themselves for a more advanced, autonomous or leadership

role.

After choosing their course of action, nurses move to the stage of reflection, which may

last a lifetime (Nathaniel, 2006). During this stage, nurses examine beliefs, values and actions.

The reflection stage includes remembering, telling the story, examining conflicts, and living with

the consequences. In remembering, nurses retain vivid mental pictures, and recall the sights,

sounds, and smells as they were experienced at that time. When telling the story, they look for

sympathetic listeners, and rely on others to hear the story and understand it from their

perspective. As the nurses tell their story, they examine the conflicts, ask themselves questions

about what really happened, and then try to find ways to avoid similar situations in the future.

Finally, nurses must live with the consequences of their actions. Often these nurses end up with

fractured relationships and may ultimately decide to leave their unit or the profession altogether.

Many seek further education in the hopes of working in a more autonomous position in which


they can correct the moral wrongs they experienced. Few nurses remain at the bedside after such

an experience. Figure 1 is included to give a depiction of the stages of moral reckoning.

Critique/Analysis of Moral Reckoning Theory

According to Peterson and Bredow (2009), there are certain criteria that should be

employed when critiquing and evaluating middle-range theories. They suggest evaluating

theories by using both internal and external criticisms. Chinn and Kramer (2008) also suggest

methods for critiquing theory which augment those of Peterson and Bredow. The criteria

suggested by these parties will be employed in the critique and analysis of this theory.

In answer to internal criticisms, the purpose of this theory was to clarify the experiences,

and subsequent consequences, of morally distressing nursing situations, and then to formulate a

logical, systematic, and explanatory theory regarding this phenomenon. The theory of moral

reckoning adequately captured the topic of not only moral distress that nurses face, but also the


moral reckoning that follows these life altering events. It is applicable to all nurses who give

direct patient care. This is evidenced by the fact that nurses who experience a morally

distressing situation often end up leaving bedside nursing and pursuing roles in which they have

more opportunity to reduce the incidence of these types of situations. However, one of the

limitations of the study was that the nurses were a highly educated and similar group, and

consisted only of nurses who were willing to talk about their experiences. Further studies need

to be done which include nurses who have not experienced a moral dilemma or who are

unwilling to talk about these experiences.

The theory also clearly defines the major components of the study and does so in a way

that is understandable. The study aimed to address gaps in knowledge by seeking answers to the

basic question of what happened in situations where nurses experienced moral distress. Moral

reckoning was the first study to identify a process which included the stages of ease, resolution,

and reflection and explained these stages in a relatively simple and clear manner.

The theory of moral reckoning was consistent with the description given, and maintained

this consistency throughout. Though the theory is new, it built upon the earlier concept of moral

distress. The arguments were well supported with literature already published on moral distress.

However, since it is a new theory, it was not able to be compared to any other studies on moral

reckoning.

This theory is a middle range theory in that it was narrower in scope than the general

moral distress theories that were published and has the ability to be applied directly to nursing

practice. It contains only four concepts and was developed from interviews with nurses


providing direct patient care. It also calls for developing tools to enable nurses to successfully

deal with moral dilemmas.

For external criticisms, the theory contains only four concepts, with no sub-concepts

being introduced, so there was no need for lengthy descriptions and explanations. The

definitions provided for the four concepts adequately reflected their meanings. The theory of

moral reckoning is unique in that it is the first study to go beyond moral distress to discover if

there was an actual process that nurses went through when faced with moral dilemmas. The

boundaries were clearly set. The data stemmed purely from nurses’ memories and perceptions,

and was not forced to fit any preconceived categories.

The assumptions represent the real world of nursing in that nurses do face moral

dilemmas in their practice. The theory can be applied to all nurses who have faced a moral

dilemma that has changed their practice and/or their life. This theory could potentially have an

impact on nursing practice because it could help retain nurses by offering ways to decrease and

successfully deal with morally distressing situations. The issues that it addresses are extremely

relevant to nursing practice and it is essential that this area be further studied.

This theory is one that can be put into practice in real-life settings. Literature on moral

distress has shown there is a high volume of nurses facing moral dilemmas, but many are unable

to cope with it successfully. Further research is needed to determine the characteristics of nurses

who experience moral distress and those who do not, and to see if this affects patient care.

Overall, the scope of the theory remains in the middle-range because it is applicable to

nursing practice. However, in some ways it might be construed as also being very broad and

only superficially touching on several other important concepts. This theory will require more


sampling and further testing in order to more fully describe the other possible concepts that may

be related to moral reckoning and to determine whether it is narrow enough to remain a middle-

range theory.

This theory could impact the future of nursing practice by describing the impact of

morally distressing situations on nurses. Yet it does more than just describe what happens in

moral reckoning; it addresses the importance of decreasing the incidence of these situations and

developing helpful tools to deal with them since moral dilemmas may ultimately impact patient

care.

Moral reckoning theory is also able to generate hypotheses that can be tested. More

research on nursing ethics is needed to shed light on nurses’ understanding of nursing ethics, and

to identify the depth of their understanding. More research is also needed to more fully develop

the concepts of moral reckoning and to identify the causes of it. There also needs to be more

sampling of nurses experiencing moral distress and reckoning, which may ultimately modify the

current theory. Lastly, research on moral reckoning should not be limited to the profession of

nursing only, as it can easily lend itself to other professions, and not only those in healthcare.

Research Generated from Moral Reckoning Theory

The theory of moral reckoning has given rise to other studies interested in the effects of

moral distress on nurses, thereby making it a theory that can be tested. It would be difficult to

assess the exact number of studies that have been done, but several studies cite the theory of

moral reckoning. One such study was done in 2007 by Zuzelo which studied the moral distress

of registered nurses employed in an urban medical center. In this study, the Moral Distress Scale

and an open-ended questionnaire were given to nurses who provided direct patient care. The


most common morally distressing events were perceived staffing levels that were unsafe,

following families’ wishes for patient care even if the nurse disagreed with the plan, continuing

life support for patients due to the families’ wishes regardless of the patients’ poor prognosis,

and carrying out orders for unnecessary tests and treatments.

Another study which cited the moral reckoning theory was done by McCarthy and Deady

(2006). This study examined literature regarding the evolution of moral distress among nursing

theorists. The authors studied the concept from the time it was introduced by Jameton to its

current use as an umbrella concept, describing its impact on health professionals and their

patients. The authors were concerned about the way moral distress has been portrayed in nursing

research and the fact that research has been largely confined to determining the prevalence of

moral distress. The authors proposed reconsidering, and possibly restructuring, research to

include a more multidisciplinary focus of this phenomenon.

Yet another study that cited moral reckoning theory was done by Austin, Kelecevic,

Goble, and Mekechuk in 2009. The focus of this study was on moral distress for nurses working

in pediatric intensive care units (PICUs). The PICU environment is high-tech and high pressure,

and effective teamwork can be compromised by moral distress. Attempts to address this issue

included tools such as shift worksheets, implementing continuing education, and encouraging

staff members to report times of distress. The authors state that the literature does not yet show

these approaches to be effective in resolving moral distress. The authors felt this study showed

that moral distress needs to be acknowledged, and also felt that sharing practice stories would

facilitate understanding among team members.


Theory Application

The theory of moral reckoning has both strengths and weaknesses. The literature review

that began as the foundation of this theory was derived from previous studies on moral distress in

nurses. Nathaniel (2003) found that research on moral distress is quite limited, both in quality

and quantity. While performing the literature review, four weaknesses became apparent. These

weaknesses were that

there were few studies available, with few informants, and though many nurses had

written about moral distress, there was little known about it;

only a handful of published studies identified moral distress, and most were unrefined

and exploratory in nature;

theoretical foundations did not adequately explain moral distress; and

there were gaps in the literature in terms of impact of moral distress on nursing care and patient outcomes.

One of the strengths of this study is that it takes a deeper look at moral distress in nursing.

Moral distress is a contributing factor in nurses’ loss of personal integrity and in dissatisfaction

with their job. This is why it is a major contributor to nurses leaving their work settings and

ultimately the nursing profession. This theory explains more clearly and thoroughly nurses’

struggles, and moves beyond the more familiar concept of moral distress. It does this by

identifying a critical juncture in nurses’ lives and then explains the process that nurses go

through which includes conflict, resolution, and reflection (Nathaniel, 2003).

Another strength of this theory is its applicability to nursing practice today. While

conducting her literature review, Nathaniel (2003) found one study that showed nearly 50% of

nurses had acted against their conscience at some point, and another one that reported that at


least one third of nurses experienced moral distress. This shows that moral dilemmas are

common in today’s nursing profession. It is essential that these nurses realize they are not alone

in wrestling with these situations, and they need to be taught the skills for dealing with these

crises.

The theory of moral reckoning could be classified as descriptive because it describes

what happens when nurses are faced with a moral dilemma. However, it can also be classified as

explanatory and seems to fit the explanatory theory mold a bit better. It identifies the concepts of

moral reckoning and explains how a morally distressing situation can contribute to nurses’

dissatisfaction with the profession and may ultimately lead to them leaving the profession.

Summary

The theory of moral reckoning in nursing is a middle-range nursing theory in that it

contains a limited number of variables, and is a theory which has shown it can be tested.

According to Nathaniel (2003), the goals of developing this theory were to clarify the

experiences, and subsequent consequences, of morally distressing nursing situations, and to

formulate a logical, systematic, and explanatory theory regarding this phenomenon.

The theory of moral reckoning uncovers a basic social process that is rarely considered

before nurses enter the workplace (Nathaniel, 2008). Nurse educators need to help students

recognize that they will experience the stage of ease (becoming, professionalizing, and

institutionalizing) early in their practice, and to be aware that this may be followed by a

situational bind. To ensure students are ready for this, nurse educators should initiate dialogue

that helps uncover conflicts between the students’ core values, professional traditions, and

institutional expectations. Educators also need to prepare students for the reality of the unique


relationships that will be formed between nurses and patients, and prepare them for the suffering

they will witness. By being forewarned about these situations, and by practicing these situations

through simulation, student nurses may be better prepared when having to face their own morally

distressing situation. This preparation may ultimately help them handle it successfully.

The theory of moral reckoning also points to a deficiency in nurses’ knowledge about

formal nursing ethics. By enriching nursing education through stronger ethics education,

teaching strategies that improve nurses’ empowerment, modeling appropriate behaviors, and

helping students learn effective ways of establishing multidisciplinary relationships, the

incidences and consequences of morally distressing situations may be reduced, thereby lessening

the negative experiences of bedside nursing. Educators also need to examine traditions of

nursing practice which inhibit meaningful dialogue with other professionals and sustain conflict

and power imbalances.

Moral distress is a pervasive problem in nursing, and contributes to the loss of personal

integrity, dissatisfaction with nursing, and ultimately the loss of nurses from the profession

(Nathaniel, 2003). Nurses report being dissatisfied with their work due to inadequate staffing

levels which results in heavy workloads, lack of a voice in decision-making processes, and

insufficient support staff. These factors combine to contribute to an increase in opportunities for

moral dilemmas, which in turn may lead nurses to leave the nursing profession altogether,

thereby perpetuating the continuance of the nursing shortage. By forewarning nurses about

moral dilemmas, and enabling them to deal with these crises, nurses may feel more empowered

and less motivated to leave the profession, ultimately affecting the current nursing shortage in a

positive way.


References

Austin, W., Kelecevic, J., Goble, E, & Mekechuk, J. (2009). An overview of moral distress and

the paediatric intensive care team. Nursing Ethics, 16(1), 57-68. doi:

10.1177/096973300809790

Chinn, P. L., & Kramer, M. K. (2008). Description and critical reflection of empiric theory. In P.

L. Chinn & M. K. Kramer (Eds.), Integrated Theory and Knowledge Development in

Nursing (7th ed., pp. 219-249). St. Louis, MO: Mosby Elsevier

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall

McCarthy, J., & Deady, R. (2006). Moral distress reconsidered. Western Journal of Nursing

Research, 28(4), 419-438. doi: 10.1177/0193945905284727

Nathaniel, A. K. (2008). Theory of moral reckoning. In M. J. Smith & P. R. Liehr (Eds.), Middle

Range Theory for Nursing (2nd ed., pp. 277-292). New York, NY: Springer Publishing

Nathaniel, A. K. (2006). Moral reckoning in nursing. Western Journal of Nursing Research,

28(4), 419-438. doi: 10.1177/0193945905284727

Nathaniel, A. K. (2003). A grounded theory in moral reckoning (Doctoral dissertation).

Retrieved from

http://wvuscholar.wvu.edu:8881//exlibris/dtl/d3_1/apache_media/6801.pdf

Peterson, S. J., & Bredow, T. S. (2009). Middle Range Theories: Application to Nursing

Research (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins

http://wvuscholar.wvu.edu:8881//exlibris/dtl/d3_1/apache_media/6801.pdf


Zuzelo, P. R. (2007). Exploring the moral distress of registered nurses. Nursing Ethics, 14(3),

344-359. doi: 10.1177/0969733007075870

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