[Facets of moral distress in nusing homes : A qualitative study with examined registered nurses].

Although the nursing home setting has some characteristic features that are relevant with respect to the development of moral distress (MD), it has so far been studied primarily in the acute care setting. The underlying classical definition of MD is increasingly criticized and broadening of this definition is encouraged to include stress due to moral uncertainty. Hence, the present qualitative study explored how nursing personnel in nursing homes experience MD. Guided interviews were conducted with 21 nurses from 5 nursing homes. The fully transcribed interviews were analyzed using Mayring's qualitative content analysis, whereby deductive (scaling and content structuring) and inductive techniques were applied. The application of scaling structuring revealed that MD was experienced mainly in a moderately severe form. The respondents reported situations where they experienced moral stress because they were impeded by barrieres to take the morally correct action. These situations were inductively summarized in the categories "unnecessary/false treatment at the end of life", "incorrect management of challenging behavior", "poor care in general" and "unnecessary hospital transfers". Decisions made by relatives and physicians were the most frequently mentioned external barrier and a lack of courage was the most frequently named internal barrier; however, the respondents also mentioned stress reactions corresponding to the category "moral uncertainty", especially during end of life care and for hospital transfer decisions, most of all when the resident's wish was not clear or due to unavailability of physicians. The results underline the necessity of a broad conception of MD at the theoretical and interventional levels.