Surface and deep causes of moral distress: A qualitative study among healthcare professionals

Background In the last 40 years, moral distress among nurses and other healthcare professionals (HCPs) has gained considerable attention. Some scholars, including Morley et al., have proposed expanding the definition of moral distress to include distress from moral constraint, conflict, uncertainty, dilemma, and tension; yet debates about this conceptualization persist.Aim of the study This study examines whether Morley's moral distress categories effectively capture moral distress experiences among HCPs, with a specific focus on the Italian context.Research design A convenience sample of 20 HCPs from a hospital in Northern Italy participated in semi-structured interviews describing morally distressing situations. Data were analyzed using deductive content analysis based on Morley's framework. As some situations did not fit existing categories, an inductive analysis was also conducted to identify additional moral distress causes.Ethical considerations This study was approved by the Ethics Committee of the University of Milan (approval no. #48/22) on 30 May 2022.Results We identified 64 morally distressing situations, 41 aligning with Morley's framework (26 constraints, 14 conflict, 1 uncertainty, and 0 dilemmas). Six situations involved multiple causes, while 17 stemmed from a new cause, namely, misconduct. We also found that all identified causes led to moral distress because they implied a perceived violation of professional values and norms. This violation emerged as a necessary condition for moral distress, leading us to develop a multi-layered model positioning violation of professional values and norms as the deep cause of moral distress, with constraint, conflict, uncertainty, and misconduct as surface causes.Conclusions Our findings suggest that Morley's framework does not fully capture moral distress's complexity. Additional sources of moral distress, such as misconduct, suggest that other triggers may be identified depending on the context. Defining moral distress solely by its surface causes risks fragmenting the concept and overlooking its deeper cause: The perceived violation of professional values and norms that leads to distress.