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Nurse Moral Distress and Cancer Pain Management: An Ethnography of Oncology Nurses in India

LeBaron, Virginia PhD, APRN; Beck, Susan L. PhD, APRN; Black, Fraser MD; Palat, Gayatri MBBS

doi: 10.1097/NCC.0000000000000136

Background: The majority of cancer patients in low- and middle-income countries (LMICs) present with late-stage, incurable disease, and basic tools to alleviate patient suffering—such as morphine—are often absent. Oncology nurses must cope with many challenges and may experience moral distress (MD), yet little research has examined this experience in LMICs.

Objective: This ethnographic study explored the experience of MD with oncology nurses (n = 37) and other providers (n = 22) in India and its potential relationship to opioid availability.

Methods: Data (semistructured interviews and field observations) were collected at a 300-bed government cancer hospital in urban South India over 9 months. Dedoose v.4.5.91 supported analysis of transcripts using a coding schema that mapped to an Integrated Model of Nurse Moral Distress and concepts that emerged from field notes.

Results: Primary themes included “We feel bad,” “We are alone and afraid,” “We are helpless,” and “We leave it.” A weak link between MD and opioid availability was found.

Conclusions: Participants described significant work-related distress, but the moral dimension to this distress was less clear as some key aspects of the Integrated Model of Nurse Moral Distress were not supported. The concept of MD may have limited applicability in settings where alternative courses of action are unknown, or not feasible, and where differing social and cultural norms influence moral sensitivity.

Implications for Practice: Improving job-related conditions is prerequisite to creating an environment where MD can manifest. Educational initiatives in LMICs must account for the role of the oncology nurse and their contextual moral and professional obligations.

Author Affiliations: Dana-Farber Cancer Institute, University of Massachusetts, Boston (Dr LeBaron); College of Nursing, University of Utah, Salt Lake City (Dr Beck); Victoria Hospice, British Columbia, Canada (Dr Black); and the International Network for Cancer Treatment and Research, India (Dr Palat).

Dr LeBaron received grant support from the American Cancer Society (grant 117214-DSCN-09-141-01-SCN; grant 121673-DSCNR-09-141-03-SCN), the Fulbright Program, and the University of Utah Graduate School to complete this research.

The authors have no conflicts of interest to disclose.

Correspondence: Virginia LeBaron, PhD, APRN, Dana-Farber Cancer Institute, 450 Brookline Ave, LW 517, Boston, MA 02215 (

Accepted for publication February 1, 2014.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins