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Making Sense of Moral Distress Within Cultural Complexity

Bressler, Toby PhD, RN, OCN; Hanna, Debra R. PhD, RN, ACNS-BC; Smith, Elizabeth MS, RN, PMHCNS-BC, CHPN

Journal of Hospice & Palliative Nursing: February 2017 - Volume 19 - Issue 1 - p 7–14
doi: 10.1097/NJH.0000000000000308
Ethics Series

The aim of this study was to explore nurses’ experiences working on a chronic ventilator-dependent unit with a predominance of elderly Orthodox Jewish patients at the end of life. Little is known about how cultural complexity creates differences between nurses’ and family’s expectations for patient care at the end of life. A qualitative study of 27 nurses was conducted using focus groups. Early interviews led to the expansion of the original question to include exploring nursesmoral distress. Content analysis revealed 3 categories of themes, one of which is highlighted in this article. The main finding was an incongruence of perspectives, described as depth-of-field dissimilarity, in which the focus and depth of perspective depend on the person doing the looking. This study suggests that depth-of-field dissimilarity can be used to develop educational strategies, clinical interventions, and research to address moral distress and cultural complexity.

Toby Bressler, PhD, RN, OCN, is vice president of Oncology Nursing, Mount Sinai Health System, New York.

Debra R. Hanna, PhD, RN, ACNS-BC, is associate professor, Molloy College, Rockville Centre, New York.

Elizabeth Smith, MS, RN, PMHCNS-BC, CHPN, is clinical nurse specialist, Maimonides Medical Center, Brooklyn, New York.

Address correspondence to Toby Bressler, PhD, RN, OCN, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1068, New York, NY 10029 (

The authors have no conflicts of interest to disclose.

© 2017 by The Hospice and Palliative Nurses Association.