Aims
Information is limited regarding moral distress in academia. It’s often not recognized even when physical, emotional, and financial harm is the outcome. This can potentially contribute to faculty attrition and a sense of failure. This study was conducted to find meaning in a 45-year nursing career that evidenced several of these events.
Method
This autoethnography was written between 1/2013 and 5/2023. Self-observation and self-reflection were the primary sources of data. A critical transformative approach guided the collection and analysis of data. Reflexive thematic analysis was employed. Multiple mirrored reflections were produced, and distinct patterns were identified. Synthesis of these patterns resulted in themes that were further analyzed for scope and associated storylines. Triangulation using external documents was employed.
Ethical Consideration
To protect the identity of individuals and institutions anonymous pseudonyms, and altered settings were used in this non interventional study. The researcher was the single participant.
Results
The cultural conflict between individual and organizational values created symptomatic moral distress that could only find relief in action. These actions resulted in consequences that blocked the author’s career advancement and resulted in physical, emotional, and financial harm. Moral distress was recognized as the antecedent to speaking truth to power and was a major turning point during this study. Sub-themes included faculty-to-faculty as well as student-to-faculty incivility and racism.
Conclusions
With moral distress identified, the self was transformed from an identity of failure to one of understanding and compassion. Culture, both individually and organizationally, was found to be a significant factor in producing and responding to the identified moral events.
Impact
Bringing this new meaning to others helps move from a reflexive stance to one that is actionable with a preventive focus. Suggestions are provided along with a call for continued research in this area.
Key Words: Moral distress, autoethnography, incivility, racism, academic culture
Introduction
Moral distress has been a concern within clinical settings for decades (Corley, 1995; Elpern, 20055; Wilkinson, 2007). However, evidence for this has not been as readily noted in the academic arena. The reasons for this are speculative but might reflect a need to accept and conform, rather than confront ethical issues that could create discomfort, especially among those on a tenure track. Budget constraints can also serve as justification for some situations that might otherwise trigger ethical dilemmas. Moral distress might not even be recognized by those experiencing it. “A lot of times, nurses are feeling these symptoms or emotions, and they don’t know what it is. They can’t put a name on it.” (Correll-Yoder,N. 2022). This was evidenced in the autoethnography from which three scenarios of moral distress, a major identified theme, are presented in this paper. Disturbing sub-themes emerged that included incivility and racism. Interestingly, the least discussed and quite possibly the most formidable influence contributing to moral distress was found within the organizational culture itself where these events took place. The author's response and associated consequences are presented in this paper along with suggestions for addressing morally challenging events that might occur in academia.
Definition of Moral Distress
Moral distress is difficult to define. In a narrative review of the literature, Morley et al. (2019) explore the narrow interpretation of this experience as problematic and suggest a more holistic understanding that is broader and more inclusive. Three criteria are identified and formed the basis for identifying it as a major theme in this autoethnography. (1) A moral event must be experienced; (2) it must include psychological distress and (3) a direct causal relationship needs to be found between (1) and (2). This event could be represented as a moral dilemma or moral uncertainty. Symptoms that surface as an outcome of moral distress have been well documented in the literature and include depression, anxiety, frustration, anger, and guilt. (Azoulay, 2020; Pappa, 2020). These can last for months and even years. Further repercussions include the need to leave the work setting, (Bulck, 2020; Petrisor, 2021 ) This can lead to a significant loss of personal income.
Conducting an extensive review of the literature, Deschenes et al., (2020) provide an in-depth concept analysis of moral distress. They identified two themes – internal and external antecedents within attributes of moral distress. They suggest that these be identified not as constraints but rather as characteristics. Ultimately, they conclude that the inability to act in the course of a moral event imposes a responsibility to change that lies not on the individual but rather on the institutional and systemic environment where these events occur. (Deschenes et al., 2020). In this autoethnography, culture played a significant role not only in the experience of those impacted by the events described but also in the construction of these events within the organizational culture where they emerged.
Cultural Context
Since this research is situated in the personal story of the researcher, it’s important to identify the cultural context. The author was raised in an Italian immigrant family in an area of New York City known as the Bronx during the years 1952-1969. She attended Roman Catholic schools for twelve years during which time she also volunteered with the Dominican Sisters of the Sick Poor in Manhattan. This provided an introduction to nursing and the social determinants of health long before these were formally identified. Following the completion of high school, two years were spent at Catholic University in Washington, DC studying philosophy and theology. This strong religious orientation framed her life choices and decisions, an ethos around “doing the right thing”. In addition, growing up in a very diverse community resulted in an acceptance and often a celebration of different races and ethnicities. In pursuing her doctoral degree, these influences led her to choose a minor in Anthropology.
The settings that were the focus of this autoethnography included nursing programs situated in various parts of the country from the East to the West Coast. Some were research-oriented, and others were not. Of the three scenarios presented in this paper, two were in a rural setting and one was urban. However, each setting evidenced a cultural context of behavior that played a significant part in constructing the moral event that took place. This is described within each scenario. To protect the identity of the institutions and individuals involved, no further specifics are provided.
Methodology
Autoethnography is a unique approach to the study of human experience. The aim is to transform the self and others by acknowledging the “inextricable link between the personal and the cultural.” (Wall, 2006). It is a transformative qualitative research method because it “changes time, requires vulnerability, embodies creativity and innovation, eliminates boundaries, honors subjectivity, and provides therapeutic benefits” Custer (2014). Different from traditional methodologies, the researcher is encouraged to incorporate personal experiences into the findings while always being reflexive of that stance. (Adams, Jones, & Ellis, 2015; Stahlke Wall, 2018). Not intending to replace traditional quantitative perspectives, autoethnography potentially adds “a new layer of depth and richness to data that originally seemed flat and sparse after statistical analysis alone” (Sell-Smith and Lax (2013).
In this study, data was compiled in a text of 314 pages that began with the researcher's early years growing up in New York City. This was written during a five year period from 1/2013 to 5/2023. The first fifty pages provide cultural context, an essential component of ethnographic research (Pelias, 2003). The remainder of the text is a collection of career-related memories that were placed on a timeline. Patterns were identified and then synthesized into initial themes. The text was re-read numerous times for a deeper understanding. Using reflexive thematic analysis, the focus was on finding meaning rather than cause and effect (Braun and Clarke 2022). Disparate data were brought together under a shared meaning that was used to construct a theme. Each theme captured a wide range of data and has its own distinct centralizing concept (Braun and Clarke 2022). The major theme that is the focus of this paper was not immediately obvious but rather was uncovered following deep analytical thinking and reference to concepts in the literature. Acknowledging the obvious bias in self-reporting, additional documents were used to triangulate the data. These included annual, preexisting, faculty reports and letters that are in the public domain.
A nursing colleague who was not previously known to the researcher and who was not aware of the context of this study was given a copy of the text. Her shared reflections added additional confirmation related to the initial themes.
Ethical Considerations
This is a non-interventional study, exclusive of any interaction or intervention with human subjects. Utilizing retrospective, anonymized, and preexisting data, this study is exempt from IRB approval (Protection of Human Subjects, 2020). The protection of the actors and institutions in the three scenarios presented in this paper was addressed by altering descriptors that might be identifiable. The time frame for these events took place over the past two decades, providing an additional shield.
The researcher is the sole participant and subject to ethical concerns (Wall, 2016). It’s not unusual for events involving moral distress to remain painful even years after they occur (Pappa, et al.2020). Care was taken to recognize symptoms of distress and to respond with self-care measures, including meditation and time away from the analysis as needed.
Findings
The study took almost a decade to complete. Although there were several interfering factors that contributed to this timeframe, the distress in recovering those memories played a significant role. It was in the retrieval of memories related to ethical conflicts that symptoms began to emerge. These included shortness of breath, tachycardia, and difficulty sleeping. The connection was not readily apparent. The symptoms were blamed on overwork and fatigue. The remedy was to stop and put the text aside for a while. However, with every return to the data, the symptoms appeared again. This back-and-forth took place over a period of five years while writing the second part of the text which dealt with specific academic work experiences. At the end of this period, a conclusion was reached. There was an absolute connection between the symptoms and the experiences being described.
At that point, identifying the phrase “moral distress” was still not evident. The focus was on the initial theme of “speaking truth to power”. It was only with deeper analysis, accomplished through multiple reads over a year, and in reviewing associated literature, that an antecedent to the empowered action taken was identified. It became clear that it was moral distress. The actions taken were the remedy for the distress that was experienced. This was a profound moment in the analysis of this study. Additional sub-themes were also identified and included incivility and racism. These were powerful sub-themes in the first and third scenarios presented in this paper.
As the primary actor in this research, I will speak in the first person in describing the following scenarios that served to define the theme of moral distress.
Scenario 1: The Struggling Nurse Practitioner Student
In this case, two faculty members were involved in determining whether an NP student should graduate. I was teaching the didactic content and a colleague was evaluating the student in his clinical placement. The latter approached me with concern about the student being unable to make appropriate decisions in the clinical arena. She voiced serious unease regarding the student graduating that spring. I suggested that we could provide the student with an incomplete and allow him time to remediate his skills to ensure he was safe to enter a practice setting independently. It was unclear how the student was able to progress to this point in his program without evidence of this deficiency. This raised a secondary cause for concern.
The two faculty members met with the student who was not receptive to the option being offered. He became angry and voiced hostile remarks that included “No one is going to stop me from graduating this spring!” A meeting with the director of the program was arranged to enlist further support for the faculty decision.
A moment of reflection is needed at this point to provide the context for this scenario. It occurred in a program located in a rural community. It was a small faculty, members of which had been employed there for many years. There were close ties to the community as well as the students. This no doubt played a role in the response of the director during the follow-up meeting. She knew the student well and described that he was struggling with many personal challenges that were likely interfering with his clinical judgment. However, this student was already offered a position in a local primary care office and delaying his graduation would jeopardize this opportunity for him, further increasing the stress in his life. Given these circumstances, the director felt strongly that we should not interfere with the student graduating. Following the meeting, the clinical faculty member received a threatening call from the student. Within days, the decision was made to give him a passing grade for the course.
In this situation, distress came from two sources: the response of the student and the reaction of the director. The student exhibited incivility in the way he spoke with and threatened both me and the clinical instructor. Even as instances of incivility in academia are increasing there is not much connection made in the literature between incivility and moral distress. In this case, however, grappling with whether or not to pass this student, combined with the student’s antagonistic and threatening behavior, created significant moral distress. In addition, the director was clearly experiencing a conflict between her role as a nursing leader and the need to care for this student in ways that she interpreted as being helpful. I attempted to speak truth to power by arguing my position with the director but it was clear that a decision to prevent this student from graduating would be unacceptable. Since I was on a tenure track, I also felt pressure to conform, even as my own ethical position was being challenged.
For several weeks that followed, I struggled with the decision that I made to pass this student. Clinical situations with the potential to cause harm were ruminating in my mind and interfering with my ability to sleep. The cultural context of my own life no doubt played a role in my distress. Growing up in a traditional Italian immigrant family, I was fully socialized into the moral imperatives of the Roman Catholic dogma. I justified the decision to pass this student as the only solution to prevent his anger from escalating into potentially doing physical harm. But the question that remained was – did I do the right thing? I responded to this distress by advising the dean of health sciences and the campus police of the situation and how it evolved. There was a need to put this responsibility in someone else’s hands. In essence, I needed to wash my hands of the guilt I felt in the decision that was made. Struggling to reconcile with that decision, I resigned from my position at the end of that year. Shortly thereafter, I experienced a physical disability that removed me from the workforce for two years. Once resolved, I was unable to find another faculty position. Age discrimination was the barrier to further employment and is addressed in a forthcoming paper. This resulted in a significant loss of income and damage to my self-esteem which took years to recover.
Scenario 2: Advancing Tenure for an Unqualified Applicant
A second episode resulting in moral distress is evident in the following situation. The cultural context for this took place in a small rural university on the East Coast where connections with the community were strong and the faculty were employed in the setting for many years. I was asked to review a packet for tenure as part of my role as a member of the recruitment and retention committee. Although I was not tenured, I was reviewing this packet alongside a tenured professor whom I respected. I viewed it as an opportunity to learn. I was familiar with the tenure process and reviewed the requirements as specified in this specific academic setting.
On the initial review, I thought perhaps the applicant had forgotten to include important evidence to support her request for tenure. I was wrong. There was little to no evidence that supported tenure as per the guidelines set up by the university. Instead, there were several thank you cards from students. There were no publications or presentations. In fact, the applicant did not appear to attend any national or even local conferences. Along with my colleague, I spent over 12 hours trying to find something to justify recommending this person for tenure. There was none that met the established criteria. At the end of that process, we agreed that we could not ethically recommend her for tenure to the committee.
Given the close ties among faculty within the department, this person soon realized that her bid for tenure was in jeopardy. She began to visit with each faculty member on the committee and campaign for their vote. Her messaging included the impact of losing tenure on her personal life. As a single parent, she was the sole provider for her family. Although moved by her circumstances, my colleague and I agreed that wavering in our position would be unethical. Our recommendation to deny tenure was sent to the committee.
The meeting descended into an emotional outpouring of tears. Objectivity was lost even as attempts were made to argue for the rationale behind our recommendation. In the end, it fell on deaf ears, and tenure was granted. There was an obvious cultural clash of values. The caring approach that is the heart of nursing took precedence over the obligation to honestly evaluate a colleague’s adherence to the guidelines established for tenure. The distress I felt quickly evolved into a moral conflict, each side battling for what they believed was right. Speaking truth to power provided some relief during the debate which ensued but the failed effort to support doing the right thing ended with exhaustion, demoralization, and significant moral distress.
It was difficult to justify the action taken by this committee. Regardless of university guidelines for tenure, they took it upon themselves to allow an otherwise unqualified applicant to obtain a lifetime position in the department. I felt strongly that this was wrong. And similar to the first situation, I couldn’t let it go without trying to do something that might prevent this from ever happening again. Speaking truth to power was not enough. During the same time frame, the department was preparing an accreditation report for the Commission on Collegiate Nursing Education (CCNE), the accrediting branch of the American Association of Colleges of Nursing (AACN). Included was an invitation to constituents of the program to submit comments prior to the accreditation visit. I used this opportunity, together with my colleague, to address some of the issues that we felt needed their attention. This scenario was one of them.
The site visit took place a few months later and the program was once again fully accredited. This presented additional distress because not only did my attempts fail to prevent this from happening again but the institution that I trusted to do the right thing also failed to respond to the issues that were raised. I no longer felt comfortable staying in that position and resigned. Interestingly, seven of my colleagues who started with me also resigned that year. There were various reasons but most reflected back on the culture of the department as important factors in their decision.
Scenario 3: Confronting Racism
The catalyst for this third scenario began over a faculty lunch with the words “we need to get rid of that big fat black woman”. At that moment, time froze, and it was difficult to piece together anything else that took place afterward. The pressure to do something, to act, was overwhelming. And yet, a rebuttal didn’t come. This was a Haitian student who was in a course I was teaching focused on health promotion. Having been raised with numerous siblings in Haiti, she brought so much depth into the class discussions sharing the challenges faced by those in a developing country. And yet in hearing those words over lunch, I did nothing. The psychological distress I felt left me feeling physically ill for days, self-medicating with one too many glasses of wine. I decided to invite this student into my office to discuss how she was doing. She shared that she was not given the same opportunity in her clinical course as other students resulting in a struggle to meet the course objectives. The person teaching that course was the faculty member who gave voice to that despicable remark over lunch.
Understanding the cultural context for what occurred in this scenario is vitally important.
The College of Nursing was located in an urban East Coast community. The faculty was predominately white, middle to upper-middle class, and mostly tenured. As in the previous examples, the bond between the faculty was strong and almost akin to a family. Given that I was approaching my final 7th year on the tenure track and by all accounts, proceeding with no issues, I had to make a decision regarding how to handle what I was feeling. The words of Thomas More were ever present in my mind: “he who is silent seems to consent” ( Oxford reference, nd ). I decided to invite the student into a program I was administering at the time. She accepted and almost immediately I felt a sense of relief. But it wouldn’t last. My actions were perceived as hostile by the faculty. I was perceived as a traitor, an outsider even though the individuals involved were never directly confronted. In this instance, I didn’t speak truth to power but rather challenged it through my actions, a far greater threat.
Speaking truth to power is problematic but can be ignored. This was the case in the first and second scenarios. But challenging truth to power is different. It elicits a response that requires reciprocal action. During my final year, I became acutely aware of the growing anger of the faculty towards me. Retaliation finally came during my tenure review, which was ultimately denied. Overt actions to sabotage my application were evident and included tampering with my evidence binder, something I only discovered when I was required to leave my position one year later. This added another layer of psychological distress in knowing that the merits of my work were not fairly evaluated.
There are some who might consider my actions in this scenario as exemplifying moral courage, but it’s complicated by the fact that I really didn’t feel I had a choice. The only way to relieve the incredible distress I felt was to take action to support this student. I find some comfort, years later, in knowing that today she has a Ph.D. in nursing.
Discussion
Consistent with the chosen definition of moral distress, each of the above scenarios represented moral events (Morley et al, 2019). In direct association with these events, the researcher experienced physical and psychological harm. There was also long-term financial harm as a consequence of losing tenure and needing to seek another faculty position in late mid-life. It’s important to recognize the impact of these situations, not only to address Provision 6 of the ANA Code of Ethics to create an ethical working environment (ANA, 2015) but also to prevent harm to our colleagues and improve faculty retention.
Although the scenarios described in this research took place between ten and twenty years ago, they are sadly still evident and some might say, increasing in academic nursing. Valentim, (2018) utilized autoethnography to analyze academic relations in a Brazilian public university and the impact these have on the health of those involved. In an evocative description of daily work-life in this setting, the author describes his naiveite regarding academia considering it a kind of “paradise on earth that could allow its members to develop values such as fairness and equality without having to enter daily battles with their own colleagues.” (Valentim, 2018). My personal beliefs were consistent with this statement and perhaps the disillusionment I felt increased the experience of moral distress for me. I was often shocked by the behavior and the lack of concern for ethical values. Similar to Valentim (2018) I noted the lack of regard for the impact various decisions made within the academy might have on society as a whole. Allowing a student to progress before he is ready impacts the care someone might receive in the community. Providing tenure to someone who has not met the standards, ensures that an ill-prepared educator will be shaping the next generation of nurses, who in turn will impact the care provided in hospitals and clinics. And the quiet, continuous, and insidious racist behavior in academic settings creates an environment, devoid of diverse voices, that perpetrates continued inequalities in the provision of healthcare.
The silence around these issues in academia promotes an atmosphere that grants normality to these behaviors and promotes their continuance. Given the scarcity of recent literature addressing these concerns, there is a need to gather more data regarding the incidence, prevalence, and outcomes of moral distress among nursing faculty. The need to conform and remain silent will make this challenging but even more important.
Recognizing Potential Antecedents to Moral Distress
There are several precipitating factors occurring today that can potentially create the right conditions for moral distress. Consideration of these was inspired by the findings in this study. Recognizing these would be helpful in encouraging faculty to share their experiences. The faculty shortage, for example, combined with the need to increase the number of nurses in the workforce, can represent a perfect storm for moral distress. Educators who are already stretched in terms of their workload are facing decisions that for some might represent ethical dilemmas. As evidenced in the first scenario, granting a passing grade to a student who is doing poorly, not only creates moral distress in the individual involved in that decision but also moral conflict when personal beliefs and values are competing with those of colleagues in administrative positions. How much of this is taking place is not known and needs to be further explored.
The second potential predisposing factor to moral distress involves nursing’s response to the faculty shortage. Programs are placing inexperienced junior faculty in positions for which most are not adequately prepared. As evidenced in the second scenario, this could lead to tenured faculty who lack the wisdom and expertise to address issues of moral uncertainty, as described in the first scenario. Anecdotal evidence indicates that some of these junior faculty recognize their inexperience and might lack the moral fortitude to make uncomfortable decisions. With little support or mentoring, an exodus from academia is likely, increasing the already significant faculty shortage (Jeffers, S. & Mariani, B, 2017).
An additional impact related to the faculty shortage is the strategy of“growing your own”. Although there are obvious benefits to this approach including a path for minority faculty to advance, there is also a less obvious risk. As noted in each of the scenarios presented, the faculty had very close, long-term relationships that were similar in nature to a family. They were bonded by a shared cultural identity that was not readily apparent to a newcomer. When confronted with challenging situations the scenarios described evolved into an “us-them” struggle. Individuals bring their own cultural identity into that setting and unless there is clarity regarding norms, roles, modes of communication, and rituals the result can lead to unclear expectations, misunderstandings, and potentially moral events.
A third potential precipitating factor to moral distress is evidenced in the final scenario. It’s easy to forget that nurses are part of a larger culture that exists outside of nursing. Sadly, this can bring racism and discrimination into the halls of academia. Although the numbers are increasing, there are still too few faculty of color. When an event occurs as the one described in the third scenario, there are often no resources to aid in resolving the issue. In addition, the person who confronts racism in these circumstances, risks becoming collateral damage as was demonstrated in this study.
Moving from Reflection to Action
Being proactive in preventing moral distress involves the promotion of an ethical climate, a type of organizational culture. It involves the conditions and practices that shape how ethical issues and concerns are identified, addressed, and acted upon. (Olson, 2021). A number of studies have examined the relationship between an ethical climate, moral distress, and nurse turnover but these have primarily been conducted in clinical settings (Koskenvuori, 2019; Simha, 2021; Kim, 2021). Unable to find any evidence for how to create an ethical climate in academic nursing, the following are some ideas that are worthy of consideration.
1. In clinical settings, there are often specific meetings focused on near misses or errors made in practice. This allows nurses not only the freedom to openly share what occurred without the fear of reprisal but more importantly, to learn from it. When situations take place in academia that produce moral distress, there is no mechanism to express that experience in a safe and protected space. Discussion is needed to explore how moral distress can be moved from a personal and often isolating experience to one that is shared and supported. Providing an opportunity to reflect on the issues that may have led to the event can prevent future incidents and resultant harm.
2. As noted in the scenarios that were presented, the organizational culture within the school or department of nursing is often part of the problem. And yet, too often it is only through time, and error that this culture becomes understood. In addition to an organizational chart, the creation of a culture chart that identifies beliefs, values, modes of behavior, communication, and relationships within the department can be very valuable. This is not unfamiliar to nursing but applied generally to those who are in our care. The time has come to use these same tools to strengthen and support nursing faculty. An organization's culture can change. It can be shaped. (Spade, 2018). Intentional discussions that are explicit about the culture of nursing in a specific academic setting could help to derail the development of potential moral events and minimize the risk of moral distress. This would also help to support newcomers to the faculty and improve retention.
3. Specific consideration needs to be given to preventing events that are generated by racism. This requires a uniquely focused strategy to help faculty identify biases that might impact their work, collegial relationships, and student success. Referencing the work of Buelow (2019) and Taylor (2008), Kechinvere et al (2023) suggest that self-reflexivity can be incorporated into existing curriculums to uncover unconscious biases which could lead to productive critical discourses around racism. The training of nursing faculty to be able to identify unconscious bias and construct anti-bias curriculums would be essential in accomplishing this outcome. Incorporating the work of self-reflection on personal biases could be a planned component of a faculty retreat/workshop. In addition, we will never be able to confront racism in the workplace unless the foot soldiers who are confronting it on the front lines are protected from collateral damage. A system needs to be in place to support these individuals.
4. The very least that can and should be implemented is the creation of a policy that addresses moral distress and how it will be managed. In a situation where a moral event occurs, the engagement of an ethics consultant can be incorporated into this policy.
Caring is at the heart of nursing and given the current challenges facing the profession, we can’t afford to neglect the emotional well-being of our colleagues, whether in academia or clinical settings.
Summary
Analysis of data from an autoethnography of a nursing career identified moral distress as a major theme. Three scenarios are presented to illuminate the predisposing factors, responses, and subsequent outcomes associated with moral distress. Both the culture of the primary actor in these scenarios as well as the organizational culture were significant influences in creating psychological stress in responding to each moral event. Attempts to speak truth to power were not helpful and in one instance, challenging truth to power resulted in a devastating outcome for the faculty member involved. Not only was there evidence of physical and emotional harm but also a long-term financial impact through the loss of tenure and the need to seek another position in late mid-life. Moving from a reflexive stance to one that is actionable is critical to proactively diffuse or eliminate moral events that can lead to moral distress. Suggestions are provided and a call for more research is needed to better understand both the precipitating factors and the best approaches to responding to these events.
Conclusion
David Graeber, a renowned anthropologist, concluded: “that it would be safer to admit to being an anarchist than to write an honest auto-ethnography of the academy.” (Graeber, 2005). No longer constrained by the risk of losing my job, I chose to begin an autoethnography to help me find meaning for the events which took place over a 45-year career in nursing. As a result of this research, I was able to reconceptualize the meaning of the identified events not as reflective of my personal failures but rather as symptomatic of external organizational constraints. With a transformed self-identity, these experiences took on a wider meaning, including proactive measures within academic settings to better address moral distress. Nursing is facing enormous challenges both in its clinical as well as academic workforce. There is an urgent need to address the issues that might precipitate moral distress and provide the caring support that is needed.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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