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Risking vulnerability : enacting moral agency in the is/ought gap in mental health care Musto, Lynn Corinne 2018

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Risking Vulnerability: Enacting Moral Agency in the Is/ought Gap in Mental Health Care  by Lynn Corinne Musto MSN, University of Victoria, 2010  A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in The Faculty of Graduate and Postdoctoral Studies (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) May 2018  © Lynn Corinne Musto, 2018 ii   The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:  Risking vulnerability: enacting moral agency in the is/ought gap in mental health care  submitted by Lynn Musto  in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Examining Committee: Patricia (Paddy) Rodney, Nursing Supervisor  Rita Schreiber, Nursing (University of Victoria) Supervisory Committee Member  Maura Macphee, Nursing Supervisory Committee Member Vicky Bungay, Nursing University Examiner Skye Barbic, Rehabilitation Sciences University Examiner   iii  Abstract The definition of moral distress (MD) was put forward 35 years ago to explain the distress nurses felt when they experienced moral compromise. Making a moral judgment, enacting moral agency, and having constraints on agency have been identified as central to the experience. The known consequences of MD for health care professionals (HCPs), health care organizations, and patient care, are significant. Yet, researchers have struggled to develop meaningful interventions. The enactment of moral agency and constraints on agency are linked together in the experience. Constraints have been identified as being internal to the HCP, or external to the HCP and rooted in the context in which HCPs work. I argue that constraints on agency are dynamic (Musto & Rodney, 2016) and that gaining clarity on MD requires exploring the experience at the intersection of structure and agency.  I engaged in this study to explore how HCPs navigated ethically challenging situations in complex acute mental health settings. I conducted this research using grounded theory (GT) methods. Grounded theory (GT) methodology allowed me to focus on the processes participants engaged in when they confronted ethical challenges. The study was multidisciplinary, conducted across two urban acute care mental health sites. I gathered data through semistructured interviews and observation.   The basic social problem participants attempted to negotiate was systemic inhumanity, or the inability of the health care system to consistently extend respect, compassion, and dignity to individuals struggling with mental health iv  issues. The resulting model, Risking Vulnerability: Enacting Moral Agency in the Is/Ought Gap, explains how participants were able to act as moral agents in the particular context they were embedded in. Participants negotiated ethical challenges relationally, by risking vulnerability; that is, holding their professional obligations, clinical expertise, and organizational processes in tension with their own vulnerability in the system. This study highlights the importance for organizations to create a relational space in which HCPs are safe to explore ethical questions about how policies and practices may dehumanize individuals struggling with mental health issues. Thereby contribute to conflicts between care that is actually given (Is) and care that aligns with professional moral obligations (Ought).   v  Lay Summary Moral distress (MD) occurs when health care providers (HCPs) are in situations where they experience an inability to practice a way that aligns with their professional values. MD arises when HCPs recognize an ethical conflict but are not able to take actions that may resolve the situation. The inability to take action may result from within the organization, such as shortages of resources affecting policies and practices, or from within the HCP from a lack of knowledge, or a lack of confidence. The purpose of this study was to explore how HCPs take action when they confront ethically challenging situations in mental health care. The findings demonstrate the importance of having organizational support so HCPs can explore ethical challenges and potential actions that can help them to practice in accordance with their ethical obligations and provide better patient care.   vi  Preface All of the work presented in this dissertation took place in the province of British Columbia. All research and associated methods were approved by the University of British Columbia’s Research Ethics Board [Certification # H14-02595], and the Fraser Health Research Ethics Board [Certification #2015-074]. Three publications resulted from this research. Information from chapter 2 of this Dissertation was the foundation for Musto, Rodney & Vanderheide (2015) Toward interventions to address moral distress: Navigating structure and agency. Nursing Ethics, 22(1), DOI: 10.1177/0969733014534879. I (Lynn Musto) was the lead author, responsible for approximately 50% of the content formation, and the manuscript composition. Dr. Rodney was involved with concept formation, contributed to the manuscript, and contributed to manuscript edits. Dr. Vanderheide also contributed to the manuscript by providing supplemental conceptual material.  Concepts from chapter 3 formed the foundation of Musto & Rodney (2016). Moving from conceptual ambiguity to knowledgeable action: Using a critical realist approach to studying moral distress. Nursing Philosophy, 17(2), doi: 10.1111/nup.12104. I was the lead author, responsible approximately 60% of the content formation, and manuscript composition. Dr. Rodney was involved with concept formation, contributed to the manuscript, and contributed to manuscript edits. Concepts from chapter 2 formed the foundation for Musto & Rodney (2018). What we know about moral distress. In (C. Ulrich & C. Grady, eds) Moral vii  distress in the health professions. Springer Publication. I was the lead author, responsible approximately 60% of the content formation, and manuscript composition. Dr. Rodney was involved with concept formation, contributed to the manuscript, and contributed to manuscript edits. I was the graduate student investigator for this research project and am responsible for all major areas of concept formation, data collection, and analysis, as well as the majority of manuscript composition. Dr. Maura McPhee was involved in the early stages of concept formation and contributed with manuscript formation. Dr. Rodney and Dr. Schreiber were involved throughout the project and contributed to concept formation and manuscript edits.   viii  Table of Contents Abstract .......................................................................................................................................................... iii Lay Summary ................................................................................................................................................... v Preface ........................................................................................................................................................... vi Table of Contents ......................................................................................................................................... viii List of Tables ................................................................................................................................................ xvii List of Figures.............................................................................................................................................. xviii List of Abbreviations ..................................................................................................................................... xix Acknowledgements ..................................................................................................................................... xxii Dedication .................................................................................................................................................. xxiv Chapter One: Situating the Study .................................................................................................................... 1 Situating the Research ................................................................................................................................ 2 The Concept of Moral Distress .................................................................................................................... 3 Challenges to the Definition of Moral Distress ........................................................................................... 5 Mental Health and Moral Distress .............................................................................................................. 9 Challenges to Broadening our Conceptualization of Moral Distress ........................................................ 11 Focus of the Research Problem ................................................................................................................. 12 Research Question .................................................................................................................................... 15 Overview of the Dissertation .................................................................................................................... 16 ix  Chapter Two Literature Review ..................................................................................................................... 19 Our Current Understanding of Moral Distress .......................................................................................... 21 Contributing Factors and Consequences .................................................................................................. 23 Canadian/British Columbia (BC) Health Care Context .............................................................................. 26 Historical Context of Moral Distress and Bioethics ................................................................................... 30 Moral Distress and Reciprocity ................................................................................................................. 35 Moral Distress in Mental Health Care....................................................................................................... 36 Moral Distress and Patient Care in Mental Health ................................................................................... 38 Summary of External Structures that Shape the Context of Care ............................................................. 42 Gaps in Our Knowledge: Reciprocity and The Moral Agent ...................................................................... 43 Relationship between the Code of Ethics and Moral Distress in Mental Health Care .............................. 44 An Evolving Definition ............................................................................................................................... 48 Making a moral judgment ............................................................................................................. 48 The concept of constraints. ........................................................................................................... 50 The role of action. ......................................................................................................................... 51 Impact of Moral Distress on HCPs ............................................................................................................ 53 Exploring related concepts ............................................................................................................ 56 Relationship Between Moral Distress and Patient Care ........................................................................... 57 Moral Distress Research in Mental Health ............................................................................................... 59 Summary of Conceptual Gaps .................................................................................................................. 61 How Reciprocity May Shape Structures and Agents ................................................................................. 61 Embodiment. ................................................................................................................................ 62 x  Embodiment and integration .......................................................................................................... 64 Neuroplasticity. ............................................................................................................................ 66 Morality and neuroscience ............................................................................................................. 67 Attachment ................................................................................................................................... 68 Review of Interventions in Moral Distress ................................................................................................ 70 Summary of interventions. ........................................................................................................... 75 Organizations. ............................................................................................................................... 77 Chapter Summary ..................................................................................................................................... 79 Chapter Three Theoretical Framing .............................................................................................................. 82 Exploration of Foundational Terms .......................................................................................................... 83 Structure ................................................................................................................................................... 83 Structures as material and non-material ....................................................................................... 85 Structures as emergent ................................................................................................................. 87 Structures as internal and external ............................................................................................... 88 Moral Agency ............................................................................................................................................ 91 Ontological Positioning ............................................................................................................................. 93 Positivism ..................................................................................................................................... 93 Post-Positivism ............................................................................................................................. 94 Constructionism ............................................................................................................................ 95 Application of the Ontological Position .................................................................................................... 99 Critical Inquiry ............................................................................................................................... 99 Relational Inquiry........................................................................................................................ 101 Methodological Application: Critical Realism ......................................................................................... 105 xi  Bridging Post-Positivism and Constructionism ....................................................................................... 110 Toward an Ontology of Moral Distress. .................................................................................................. 114 Methodological Pluralism in Critical Realism ......................................................................................... 116 Generating Theory in Critical Realism. ........................................................................................ 117 Critiques of theorizing in critical realism ..................................................................................... 119 Summary of Implications for Moral Distress Research ........................................................................... 122 Chapter Four: Methodology ........................................................................................................................ 125 Review of the Research Problem and Questions .................................................................................... 125 Situating Myself and the Research ......................................................................................................... 127 Origins and Evolution of Grounded Theory Methodology ...................................................................... 130 Historical Background ............................................................................................................................. 130 The historical impetus for grounded theory. ............................................................................... 130 Positivist grounded theory ............................................................................................................ 132 Social constructionist grounded theory ........................................................................................ 133 Contemporary Grounded Theory ............................................................................................................ 134 Constructionist grounded theory ................................................................................................ 134 Summary of GTM for This Study. ............................................................................................................ 135 Conducting Grounded Theory ................................................................................................................. 136 Inclusion criteria. ........................................................................................................................ 136 Exclusion criteria. ........................................................................................................................ 137 Sampling ................................................................................................................................................. 137 Sensitizing concepts .................................................................................................................... 138 xii  Sample Size ............................................................................................................................................. 139 Location .................................................................................................................................................. 139 Gaining Access and Recruitment ............................................................................................................ 140 Data Sources ........................................................................................................................................... 142 Participants ............................................................................................................................................. 142 Description of participants .......................................................................................................... 143 Data Collection ....................................................................................................................................... 144 Interviews ................................................................................................................................... 144 Participant observation ............................................................................................................... 145 Document review ........................................................................................................................ 147 Data Analysis .......................................................................................................................................... 148 Memoing .................................................................................................................................... 148 Coding ......................................................................................................................................... 149 Constant comparison .................................................................................................................. 151 Theoretical sampling ................................................................................................................... 152 Rigor and Evaluation of the Resulting Grounded Theory ........................................................................ 154 Reflexivity ................................................................................................................................... 155 Ethical Considerations ............................................................................................................................ 158 Informed Consent ....................................................................................................................... 158 Confidentiality ........................................................................................................................................ 160 Researcher-Participant Relationship ........................................................................................... 161 Dissemination of Findings ....................................................................................................................... 162 Chapter 5 Findings ....................................................................................................................................... 164 xiii  Context of the Study ............................................................................................................................... 166 Offloading responsibility for care ................................................................................................ 169 Safety and high-stakes situations ................................................................................................ 170 Systemic Inhumanity ............................................................................................................................... 171 Risking Vulnerability ............................................................................................................................... 174 Working through Team Relationships .................................................................................................... 178 Finding Boundaries ..................................................................................................................... 179 Strategizing actions ..................................................................................................................... 188 Fostering outside relationships ................................................................................................... 193 Summary..................................................................................................................................... 198 Struggling with Inhumanity .................................................................................................................... 200 Rationalizing action. .................................................................................................................... 205 Distancing self ............................................................................................................................. 217 Living with bullying ..................................................................................................................... 222 Bullying from superiors ................................................................................................................. 223 Bullying from peers ....................................................................................................................... 226 Bullying of patients ....................................................................................................................... 229 Focusing on the immediate relationship ..................................................................................... 234 Summary ................................................................................................................................................. 240 Pushing Back ........................................................................................................................................... 241 Holding fast to professional identity ........................................................................................... 243 Professional values guiding practice ............................................................................................. 245 Using shared clinical knowledge ................................................................................................... 247 Fostering collaborative organizational relationships .................................................................... 249 xiv  Taking strategic action ................................................................................................................ 253 Relying on outside support ......................................................................................................... 259 Accepting the consequences ....................................................................................................... 263 Summary of the Findings ........................................................................................................................ 268 Chapter 6 Discussion ................................................................................................................................... 271 Summary of the Study ............................................................................................................................ 273 Contributions to Knowledge ................................................................................................................... 275 Structural Influences on Moral Agency ................................................................................................... 275 Exploring Complexity .............................................................................................................................. 277 Implications for the Definition of Moral Distress .................................................................................... 278 Constraints, moral agency, and context ...................................................................................... 279 Understanding the relationship between constraints and moral agency..................................... 279 Constraints on moral agency as an assault on HCPs’ professional identity. ................................. 282 Systemic Inhumanity ............................................................................................................................... 284 Humanity and inhumanity .......................................................................................................... 286 The influence of perspectives of autonomy on the treatment of patients ................................... 286 Relational Approach to Care ....................................................................................................... 289 The relational nature of agency within broader social structures ................................................ 290 Societal structures that influenced care ...................................................................................... 291 The discourse of efficiency superseding the value of patient-centered care in decision-making 292 Offloading Responsibility for Care, and Safety and High-Stakes Situations ........................................... 295 Increasing violence and antisocial behaviour .............................................................................. 297 Worthy and unworthy mental health patients ............................................................................ 299 xv  Deinstitutionalization and reinstitutionalization through the criminalization of mental illness .. 301 Political and Policy Tensions and the Influence of the Context of Care .................................................. 308 Values versus cost ....................................................................................................................... 309 Hollow policy .............................................................................................................................. 310 The Role of Leadership ............................................................................................................................ 312 The Influence of Leadership on Moral Agency ........................................................................................ 313 Leadership and Policy ............................................................................................................................. 316 The Influence of Leadership Support in Situations of Unsafe Practice and Bullying ............................... 317 Team Influences on Moral Agency.......................................................................................................... 322 Conclusion ............................................................................................................................................... 327 Chapter 7 Implications and Opportunities for Further Inquiry and Action ................................................. 332 Theoretical Implications ......................................................................................................................... 333 Drawing on Theoretical Concepts from Across Disciplines .......................................................... 335 Power and Moral Agency ............................................................................................................ 338 Practice Implications ............................................................................................................................... 338 Tipping in and out of Moral Distress: Influences ......................................................................... 338 Leadership and the Creation of Space for Ethical Discussions ..................................................... 340 Clinical Supervision ..................................................................................................................... 342 Implications for Education ...................................................................................................................... 343 Policy Implications .................................................................................................................................. 346 Research Implications ............................................................................................................................. 349 Limitations of This Study ......................................................................................................................... 350 xvi  Conclusion ............................................................................................................................................... 352 References ................................................................................................................................................... 354 Appendix A Moral Distress Definitions ........................................................................................................ 391 Appendix B Individual and Structures: Interactions .................................................................................... 394 Appendix C Information Letter .................................................................................................................... 395 Appendix D Interview Schedule .................................................................................................................. 397 Appendix E Model ....................................................................................................................................... 398    xvii  List of Tables Table 1 Participant Characteristics ................................................................... 144 Table 2 Definitions of Moral Distress by Author/ Date ...................................... 391    xviii  List of Figures  Figure 1 Risking Vulnerability: Categories of Action ......................................... 165 Figure 2 Risking Vulnerability: Working through Team Relationships .............. 178 Figure 3 Risking Vulnerability: Struggling with Inhumanity ............................... 200 Figure 4 Risking Vulnerability: Pushing Back ................................................... 241 Figure 5 Risking Vulnerability ........................................................................... 271 Figure 6 Interactions between Individuals and Structures ................................ 394 xix  List of Abbreviations  APD  Antisocial personality disorder BC  British Columbia BPD  Borderline Personality Disorder BSP  Basic social process CHT  Canada Health Transfer CIHI  Canadian Institute for Health Information CLBC  Community Living British Columbia CMA  Canadian Medical Association CTAS  Canadian Triage and Acuity Scale DD  Dual diagnosis ED  Emergency Department EHS  Emergency Health Services ER  Emergency FASD  Fetal Alcohol Spectrum Disorder FPH  Forensic Provincial Hospital FTR  Failure to rescue GT  Grounded theory GTC  Grounded Theory Club GTM  Grounded Theory Methodology HA  Health Authorities xx  HCP  Health Care Professional HEC  HealthCare Ethics Committee Forum HR  Human Resources HREB  Human Research Ethics Board ICU  Intensive Care Unit ID  Intellectual disability MD  Moral distress MDS  Moral Distress Scale MDT  Moral Distress Thermometer MH  Mental health MHA  Mental Health Act MHSU Mental Health & Substance Use MoH  Ministry of Health MSE  Mental Status Exam NICU  Neonatal intensive care unit OD  Overdose PCC  Patient Care Coordinated PDD  Pervasive Developmental Disorder PICU  Pediatric Intensive Care Unit PRN   Pro Re Nata, meaning “as necessary” PTSD  Post-Traumatic Stress Disorder RN  Registered Nurses SI  Symbolic interactionism xxi  SR  Security room   xxii  Acknowledgements I express my gratitude and appreciation to the health care professionals who agreed to participate to participate in this research. All the participants in this study discussed situations from practice that reflected their desire to provide care that aligned with their professional obligations to patients. They also expressed the desire to see changes across the acute care mental health system that ultimately supported the provision of care that extended dignity, respect, and compassion to individuals’ struggling with mental health issues. I deeply appreciate the support of my supervisory committee (Dr. Patricia Rodney, Dr. Maura MacPhee, and Dr. Rita Schreiber). My committee members have alternated between encouraging and supporting my academic endeavour, and challenging and pushing my thinking. They made themselves available to me in moments of crisis when I wanted to quit, and created external structure to keep me moving when I got stuck in the research and writing process. They are all generous scholars --generous with their knowledge, their time, and their expertise. Their involvement in my academic journey has shaped and changed me to my core. I cherish the example of mentorship that they have given me and hope to extend that generosity to students I have the privilege of mentoring in the future. I also want to acknowledge the financial support I received from Canadian Institute for Health Research and from University of British Columbia (UBC) Faculty of Graduate Studies. Without this funding support, my graduate studies would not have been possible. xxiii  It has been a privilege to study at the UBC School of Nursing. I have had the opportunity to study with academic nurse leaders in Canada whose scholarship continues to shape healthcare policy and practice. I am also grateful for my fellow learners in the PhD program at UBC. I also want to acknowledge the coolest club on the campus the University of Victoria, the Grounded Theory Club (GTC). I started attending in 2008, to begin learning about grounded theory. The GTC is made up of a dedicated group of scholars and life long learners who have greatly contributed to my growth as a scholar and a grounded theorist. Finally, I could not have done this work without the ongoing support of friends and family. I want to thank my friends who have tolerated, and respected, my long absences from their social world. Yet, they warmly invite me back in when I have time. Foremost, I want to thank my family who have been on this long journey with me. Ian, who has literal been my cheerleader; Cora, who has reminded me of how proud she is of me and pushed me to completion; and my long-suffering husband Mark, who has steadfastly and unwaveringly supported me at each step of this journey. I love you all.   xxiv  Dedication  To my family, Mark, Cora, and Ian. Without your support, this research would not be possible. 1  Chapter One: Situating the Study I had been nursing for about five years and was working as a Psychiatric Liaison Nurse (PLN) in the ED when one day a woman came in seeking help.  She expressed feeling hopeless and was worried that she was going to harm herself, as she had suffered a significant loss in the past six months and was having difficulty moving on after that loss.  She had no plan to harm herself and had come to the hospital, because, she stated, she did not know where else to go for help.  The ED physician certified the woman under the Mental Health Act.  At that time, a draft policy existed that stated that all certified patients had to be stripped of their belongings, placed in hospital pajamas, and locked in the security room. In my clinical judgment, this woman did not present an active suicide or elopement risk.  I also believed that locking her in the security room was not in the best interests of the patient. In fact, I believed that the experience could potentially serve to increase her sense of isolation and hopelessness, adding to her mental health difficulties. I expressed my concerns to the physician and the head nurse and was told that if I did not comply with the draft policy, the security guards would be called in to assist another nurse in making sure the draft policy was followed. I complied with the order and the policy, but left my position in the ED within the next few months. This incident has stayed with me and prompted my entry into graduate studies in nursing.     In my clinical judgment this woman did not present an active suicide or elopement risk.  I also believed that locking her in the security room was not in the best interest of the patient. In fact, I believed that the experience could potentially serve to further increase her sense of isolation and hopelessness, adding to her mental health 2  Situating the Research Although the story recounted above is from my own experience as a nurse, many health care professionals (HCPs) have similar experiences where they felt compelled to compromise their personal and professional values due to circumstances that they perceived as being beyond their control. This incident occurred approximately five years into my nursing practice and it became the beginning of an intentional journey in my personal and professional life. Although I could not articulate it at the time, this journey was about understanding the integral role of values in my life, and how I enacted those values as a nurse. The experience highlighted a series of questions that had been bubbling beneath the surface of my daily practice and related to how I lived out my professional obligations to the patients I cared for. Questions emerged for me such as: How do nurses provide compassionate care when they are pressed for time and have no privacy to talk about patients’ concerns? How can nurses be a part of drafting policies that put the needs of the department before the best interest of the patient? The questions I asked were accompanied by feelings of confusion, anger, sadness, and in this particular case, anguish, as I struggled to do what I believed was in the best interest of the patient. The intentional journey I began was embedded in a desire to understand what it meant to be a “good nurse.” Initially, I attributed my struggles to a lack of clinical knowledge and believed that if I had more clinical knowledge and experience I would be able to answer such questions. As I grappled with these questions, I began to recognize the 3  conflicting values inherent in certain situations and I became exposed to the concept of moral distress (MD). I also began to wonder about how HCPs, such as myself, could be supported to work through situations and responses that led to the experience of MD, while continuing to act in the best interest of the patient. The Concept of Moral Distress The concept of moral distress resonated deeply within me. The original definition by philosopher Andrew Jameton (1984), in his study of nurses, stated that the experience arises “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6), as was certainly the case for me with the woman seeking help in the Emergency Department (ED). Interestingly, the key for Jameton (1993), in distinguishing a nurse’s story of MD from a story about a moral dilemma, was that he recognized that the nurse had already made a moral judgment about what was the right thing to do in that situation, subsequently experiencing distress (1993, p. 543). What makes this interesting is that it becomes apparent in his elaboration that it was the emotional component of the story that provided cues that something other than conflicting moral principles was taking place. However, Jameton did not explicitly connect his definition or ensuing explanation to the emotional or psychological aspects of the experience. Despite the fact that the term moral distress named an important phenomenon for me at a crucial point in my career, I found that the definition put forth by Jameton (1984) was neither adequate to explain the depth of the 4  disturbance created by the experience, nor did it capture the complexity of the situation associated with MD. The definition of moral distress seemed linear and did not attend to the contextual factors that enabled and supported the institutional constraints. For example, the contextual factors that led to the development of the draft policy described in my story were subsumed under the broad category “institutional constraints” without an actual understanding of the reasons for the policy. My experience led me to conduct a master’s thesis study at the University of Victoria on the experience of moral distress in mental health care. As I engaged in this research process, along with my subsequent doctoral studies at the University of British Columbia and my reviews of the evolving literature on the concept, I began to realize that the experience of MD was comprised of a complex and relational interplay between organizational and societal structures, and agents trying to act morally. For HCPs to act morally means to fulfill their moral obligations to patients by practicing in accordance with their Standards of Practice and Code of Ethics (Peter & Liaschenko, 2013). In using the word “complex,” I am referring to all the attributes and processes that influence and shape human development and behaviour, as these factors influence an individual’s capacity for agency in a given situation. In the context of this dissertation, “factors” refer to the relatively fixed attributes in health care that shape behaviour, such as policy. “Processes” refer to the biological, neuro-physiological, and psychological developmental processes that are shaped by social structures, and the ideologies, and assumptions that 5  underpin these social structures. In using the term “relational” I am aware that it is used in the ethics and health care literature in two different ways. The first is in reference to interpersonal relationships (Bergum, 2013), and the second refers to how individuals are situated in a connected web of structural relationships in organizations and larger sociopolitical systems (Bergum, 2013; Doane & Varcoe, 2013; Rodney, Kadyschuk, et al., 2013; Sherwin, 1998). I elaborate further on my understanding of “relational” in Chapter Three in the discussion of relational inquiry. In the context of this dissertation, I am using the term “relational” to be inclusive of both definitions of relational, as I believe many of the challenges and critiques of the concept of moral distress are a result of the separation of the inter and intra-personal relationships from the contexts that shape these relationships (Musto, Rodney & Vanderheide, 2015). Challenges to the Definition of Moral Distress  The concept of moral distress has also come to resonate deeply within the nursing community. Not long after Jameton’s initial work, nurse researchers began to apply the concept in specific nursing areas such as labour and delivery, critical-care, military nursing, nursing students, mental health, and medical/surgical units (Deady & McCarthy, 2010; Fry et al., 2002; Kelly, 1998; Ohnishi et al., 2010; Wilkinson, 1987, 1989). Challenges with the definition began to emerge immediately. The original definition, as conceptualized by Jameton (1984), was predicated on three main assumptions: (a) that nurses had made a moral judgment (b) that they did not act on that moral judgment, and (c) that 6  inaction was related to institutional constraints. Wilkinson (1987) was the first to refine the definition by explicitly acknowledging the psychological and emotional impact of the experience. Wilkinson’s definition stated that moral distress is defined as “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision” (1988, p. 16). Also, although not explicit in her analysis, Wilkinson demonstrated that moral distress occurred even when nurses did take action. I consider that one of the flaws of the original definition is the assumption that nurses did not take action, because, although early research based on Jameton’s definition clearly described nurses taking action, that action was not recognized as such (Jameton, 1993). In response to Wilkinson’s work, Jameton (1993) further refined his definition to include initial and reactive distress to decrease ambiguity. He stated that, “initial distress involves the feelings of frustration, anger, and anxiety people experience when faced with institutional obstacles and conflict with others about values. Reactive distress is the distress that people feel when they do not act upon their initial distress” (p. 544). Although his refinement explicitly recognized the emotional aspects of the experience, Jameton maintained the assumption that moral distress is a linear experience with a cause (making a moral judgment), and an effect (not acting on that judgment). What Jameton also acknowledged with his refinement of the definition was that, in some cases, nurses did take action. However, there continued to be ambiguity in the definition in regard to nurses who did take action, yet still experienced moral distress. 7  As nurse researchers have worked with the concept of MD, the definition continues to evolve; yet problems remain. One of the main challenges currently raised by researchers is that the definition lacks conceptual clarity (McCarthy & Deady, 2008; Pauly, Varcoe, & Storch, 2012; Varcoe et al., 2012). Consequently, there is an uneven emphasis on different aspects of the definition (Hanna, 2004; McCarthy & Deady, 2008; Musto & Rodney, 2018; Musto, Rodney, & Vanderheide, 2015) in the research. For example, researchers point out that the definition lends itself to possible conflation between moral distress and psychological or emotional distress, leading to a call for researchers to focus on the ethical component of moral distress (McCarthy & Deady, 2008). Researchers have also questioned the idea of “constraints,” calling for further elaboration, because there is recognition that constraints internal to an individual and external constraints such as institutional policies may inhibit a person from taking action, or render his or her actions ineffective (Huffman & Rittenmeyer, 2012; Musto & Rodney, 2018; Musto & Rodney, 2016; Rodney & Varcoe, 2012; Webster & Baylis, 2000). Although researchers continue to question and refine the definition of moral distress, they tend to use Jameton’s original definition as a foundation on which to build. The result is a growing list of definitions of moral distress without full clarification of the theoretical orientations and constructs that underpin the definition. Moving beyond this impasse is essential if we are going to develop interventions that will be effective in assisting HCPs as they work through moral conflict and meet their moral obligations. Scholars developing knowledge from 8  research outside the discipline of nursing can be the impetus necessary for understanding moral distress in new ways. Fortunately, there are promising fields of inquiry that can help. In the past two decades, advances have been made in our understanding of the depth of brain and body integration related to physical and emotional health (Doige, 2007; Narvaez, 2014; Siegel, 2012). There is also increasing recognition of the influence emotions can have on physical health and vice versa (Finset, 2012; Levine, 1997; Sapolsky, 2004). More recently, researchers in neuroscience have begun to speculate on the connection between morality and brain functioning (Bluhm, 2014; Greene, 2003; Killen & Smetana, 2008; Narvaez, 2014). Research being conducted across these disciplines points to a tightly intertwined and reciprocal1 relationship between agents and structures (Musto & Rodney, 2016). One further critique of the concept of moral distress is that research has largely focused on the nursing profession; this has led to the implied suggestion that nurses are the only HCPs that struggle with the issue (Hanna, 2004). Yes studies on MD are emerging across health care disciplines; for example, those in psychology (Austin et al., 2005), medicine (Hamric & Blackhall, 2007; Mack, 2013), physiotherapy (Carpenter, 2010), social work (Mänttäri‐van der Kuip, 2016) and pharmacy (Kalvemark Sporrong, Höglund, & Arnetz, 2006). These                                             1 In the Oxford dictionary reciprocate has several meanings including “to give and receive mutually” and, as “part of a machine, to move forward and backward.” In using the term reciprocity, I draw on the idea that people are in a back and forth relationship with their environment and that they influence each other, although not always in a mutually beneficial way. 9  studies indicate that MD is experienced across disciplines; however, the circumstances that provoke the experience are different for each discipline. In initiating this study, I believed this information supported the need to broaden our perspective across professions and across disciplinary knowledge in order to bring conceptual clarity to MD. More recently, evidence has emerged indicating that health care managers also experience moral distress related to having to address competing responsibilities (Mitton et al., 2011). Mental Health and Moral Distress   As noted above, critiques regarding moral distress include the understanding that it has been studied widely with nurses working in acute medical areas (Hamric, 2012). Just as research on MD has focused too narrowly on specific professions, it has also maintained a narrow scope on areas of practice. Thus, the area of psychiatry has largely been understudied in the context of MD (Austin, Bergum, & Goldberg, 2003; Deady & McCarthy, 2010; Nuttgens & Chang, 2013; Ohnishi et al., 2010). This being said, a (slowly) growing number of studies have been conducted in psychiatry in an attempt to identify the issues that give rise to the experience of MD, along with the barriers or constraints to action (Austin et al., 2005; Deady & McCarthy, 2010; Hamaideh, 2014; Musto & Schreiber, 2012). While these studies have added to our general knowledge base regarding MD, they also indicate that MD may also result from issues that are unique to mental health care delivery. Examples of some of these issues include coercion, restraint, enforced medication and the excessive use of 10  force (Deady & McCarthy, 2010; Musto & Schreiber, 2012). While not all nurses working in mental health experience MD as a result of using coercion (Lind et al., 2004), for those who do, the experience may have an effect on the quality of the therapeutic relationship between the HCP and their patient, and lead to the experience of MD. Given that HCPs’ concerns are around quality of care delivery, the experience of moral distress may signal erosions in the quality and safety of patient care delivery (Rodney, Kadyschuk, et al., 2013). To explore the concept of moral distress with the intention of integrating knowledge within psychiatry as well as other areas, it has been necessary for me to step back from Jameton’s definition and examine it within the broader context of structures and agents, asking questions such as: What are the structures at play in promoting or ameliorating moral distress? How are they created, sustained, and changed? How do they shape/ influence society and values? (Rodney, Buckley, et al., 2013; Rodney, Kadyschuk, et al., 2013). I also needed to ask questions about moral agents; for example, what is the nature of moral agency—that is, HCPs’ ability to act in a way that brings about a moral end goal? How do moral agents understand or develop values? How does someone demonstrate moral agency, particularly in the context of problematic structures? Such questioning is consistent with my understanding of relationships as inclusive of inter and intra-personal structures, as well as the contextual features that shape relationships (Musto, Rodney & Vanderheide, 2015). 11  Challenges to Broadening our Conceptualization of Moral Distress There are challenges to broadening the definition of moral distress. These are (at least) twofold. First, when Jameton (1984, 1993) introduced moral distress as a moral judgment disguised as a moral dilemma, he firmly planted the experience within the confines of ethical theory. The result of rooting a deeply emotional experience within ethical theory is that the experience of MD, which begins with, or comes to, our awareness as a bodily experience, is now cut off from the body. Traditional ethical theory has historically viewed rationality as the way to working through ethical situations (Arras, 2010; Rodney, Burgess, et al., 2013). Although rationality is necessary for the examination of situations fraught with conflicting values and ethical principles, it is not sufficient for understanding or making decisions laden with emotional angst (Damasio, 1994). Second, a concern with ethical theory is that it has developed largely in isolation from other disciplines, such as moral development and neuroscience (Flanagan, 1991, 1996). Such disciplines could shed light on an individual’s ethical decision-making processes. Both of these challenges have constrained the efforts to develop a comprehensive understanding of concepts that underpin MD and how we enact our moral agency. Without a clearer understanding of MD that incorporates diverse theoretical orientations, it is difficult to develop or evaluate interventions that are effective in helping HCPs work through the experience. 12  Focus of the Research Problem Reflected in the newer literature on MD, including publications that resulted from a symposium on moral distress (HEC Forum, 2012), is the desire of many clinicians and researchers to move forward with actions that support HCPs to ameliorate the experience of MD and that can create change in the broader sociopolitical structures that inhibit ethical practice (Hamric, 2012; Musto et al., 2015; Musto & Rodney, 2016; Rodney, Buckley, et al., 2013; Varcoe et al., 2012). The desire to move toward action is understandable, given that research findings suggest that there are links between and among the experience of MD, patient outcomes, short and long-term impacts on staff, and the effect of staff turnover on patient care (Epstein & Hamric, 2009; Hyatt, 2017; Webster & Baylis, 2000; Wilkinson, 1987).  As well, given that MD generates significant issues in terms of its impact on attrition and intention to leave (Austin, Saylor, & Finley, 2016; Sauerland et al., 2014; Whitehead et al., 2015), both practitioners and researchers have begun to call for interventions that will help HCPs manage the experience without suffering long-term consequences. Researchers are also pointing to the importance of viewing MD as a broader organizational issue (Hamric, 2012; Milliken, 2018; Pauly et al., 2012). However, knowing how, where, and which actions might be most effective becomes difficult when the concept of MD itself lacks conceptual clarity and also lacks sufficient theoretical grounding to frame subsequent actions. Taking action in order to develop interventions becomes 13  even more complex when we begin to consider interventions that include both structures and agents. The anecdote recounted at the beginning of this chapter points to the complexity of the experience of MD and the interplay between structures (the ED and policies), and agents (myself and others involved in the incident). As such, it serves as an entry point into the process of this dissertation. The first step in exploring how the interplay between structure and agent influences moral distress is acknowledging that I view moral distress as embodied.2 In approaching MD as an embodied experience, I attended to the reciprocal relationship between agents and structures. Bergum (2013) tells us that, “[e]mbodiment calls for healing the split between mind and body so that scientific knowledge and human compassion are given equal weight” (p.132). In a similar way, I sought to connect the felt (sensory) experience of MD in the body with the                                             2 In taking the position that moral distress is an embodied experience, I am referring to how individuals take in and make sense of information as they navigate living in the world. We take in information about the world around us through our senses and neurobiological processes influence how individuals make sense of incoming information. Damasio (1999) refers to the separation of mind and body in science as “the lack of an evolutionary perspective in the study of the brain and mind” (p.39). Damasio is referring to how the brain processes information beginning outside of awareness with the areas of the brain responsible for maintaining homeostasis. Over the past 20 years, researchers have started incorporating an evolutionary perspective into different areas of study, e.g. attachment and moral development, to provide comprehensive explanations for the dynamic nature of the environment-brain-body relationship. Rushton et al. (2013) provide an example of taking an evolutionary, embodied perspective in their work on moral distress. For examples from the areas of attachment and moral development, readers are referred to Siegel (2012) and Narvaez (2014). I pick up this discussion of embodiment in chapter two. 14  theory that underpins the experience. Understanding MD as an embodied experience inseparable from the context in which we work provided a comprehensive, integrated approach to inquiry into the experience. It is my hope that this will move us further toward clarity in our theoretical orientation and constructs within, and across, health care practice contexts. I have also worked toward an embodied understanding of MD so that it might contribute to insights into how the brain and body together experience a violation of moral boundaries3. Due to the lack of conceptual clarity, our current approach to the development of interventions is a trial and error approach whereby researchers trial an intervention but are unable to say with any certainty if, or why, the intervention was effective (Beumer, 2008; Kälvemark et al., 2004). Knowledge gleaned from conceptualizing MD as embodied may set the stage for thoughtful interventions specific to the experience. Throughout, it is my premise that understanding the concept of MD requires researchers to understand the agent as a whole being in the context of the structures in which he or she is situated (Musto et al., 2015).                                             3 Guthiel and Gabbard (1993) defined a violation as the harmful crossing of a boundary. They suggest that a boundary crossing may or may not be harmful depending on context and situation facts. By extending this idea to include morals, I am suggesting that the harm resulting from a moral boundary violation may be moral distress. 15  Research Question  In initiating this study, I proposed that appreciating the experience of moral distress as an embodied experience that encompasses a reciprocal relationship between health care structures and agents will help bring clarity to our understanding of MD. I further argued that this will be helpful in all areas of health care, in particular, the areas that are understudied such as mental health. Finally, I argued that this could be accomplished by examining how health care professionals enact their moral agency within the health care structures where they work. The specific research question I hoped to answer was: How do HCPs in mental health navigate morally charged situations and enact their moral agency within their health care organizations? This research question was directed at understanding what occurs at the intersection of structure and agency as HCPs seek to practice in alignment with their Standards of Practice and Code of Ethics. Toward this end, I conducted a qualitative study for this dissertation, with the aim of discovering how HCPs enact their moral agency within their immediate work environment of mental health care. Conducting qualitative research allowed me to explore with the participant the processes they engaged in, along with how the immediate context both supported, and at the same time inhibited, moral agency. As well, I examined participants’ perceptions of how broader health care structures, such as policy and ideology, influenced the enactment of their moral agency. More specifically, I undertook a grounded theory (GT) study that resulted in a substantive theory that 16  explains the embodied processes mental health care providers engage in when they encounter morally distressing situations. Overview of the Dissertation  This dissertation has seven chapters in total. In this first chapter I have presented a brief overview of the definition of moral distress and identified the gaps in our understanding of the concept of MD. I also presented some of the reasons for these gaps and the potential means to reconcile them within the context of mental health care. In Chapter Two I explore the underlying constructs of MD within a broader disciplinary context. I present a more comprehensive overview of the relevant literature on MD, identifying the strengths and gaps in research related to mental health. As well, I touch upon historical debates in the literature related to moral psychology and moral development, and the current debates related to morality and neuroscience. I discuss how the implications of current debates may move us toward clarity in understanding MD. Drawing on literature related to the relationship between agents and structure, I integrate this literature and present a coherent argument for examining the reciprocal and dynamic relationship that exists between structures and agents. In Chapter Three I discuss critical realism and constructionism, as they provided the conceptual foundations for framing my approach to this research. I examine how a critical realist perspective allowed me to attend to complexity in the experiences of MD in mental health care. It is my contention that using a 17  constructionist perspective enabled me to explore the meaning of moral situations with participants. This allowed me to better understand how participants made sense of their moral obligations and what influenced their actions as moral agents. In explicating my research methodology and methods in Chapter Four, I present an historical overview of GT methods, moving from traditional GT to contemporary constructionist applications. The key tenets of GT are discussed along with the rationale for my choice of GT methods for the research. Details regarding the processes I used to conduct the research are provided, including information about recruitment and sampling; inclusion and exclusion criteria; rationale for the selection of sites; methods for data collection and analysis; ethical conduct of the research; and dissemination of findings. In Chapter Five, I present the findings of this GT study, which resulted in the theory addressing vulnerability, moral agency, and moral distress. In Chapter Six, I discuss the key findings in the context of the extant literature. I begin by discussing how the findings influence our understanding of the definition of moral distress and moral agency. Finally, in Chapter Seven, I outline implicationsions directed at supporting HCPs’ enactment of moral agency in order to practice in alignment with their professional obligations to society. I also present suggestions for further theoretical development of the concept of moral distress. Practice implications focus on the importance of leadership in creating space for discussions on ethical issues. Educational implications include ethics education that includes both laying a foundation for ethical practice, and teaching students 18  to develop moral resilience. I argue this education should also include interprofessional ethics education. Lastly, I discuss policy implications, and suggestions for further research.  19  Chapter Two Literature Review Understanding individual psychologies and the social forces that shape them are important tasks for ethics. It is one thing to determine what, ethically and politically, people ought to do, yet another to grasp the conditions under which they are likely to recognize what they should do, summon the motivation to do it, overcome inhibitions and obstacles to doing it, and in the end do something like what is required. Margaret Urban Walker (2004) In this chapter, I explore conceptual and empirical work to move toward a broader conceptualization of moral distress—a conceptualization that enabled me to set the stage in my dissertation research for inquiry that informed the development of the intentional, measurable, and ultimately effective, interventions I suggest in Chapter Seven. As I indicated in Chapter One, my research question was directed at understanding what occurs at the intersection of structure and agency as HCPs seek to enact their moral agency and practice according to their Standards of Practice and Code of Ethics. I took this approach for two reasons: the first was that Jameton (1984) definition of moral distress inextricably links the action or inaction of the agent to the context in which he or she works. The second reason was the possibility that illuminating the reciprocal influence between structure and agent could help clarify the ambiguities that exist within the definition I noted in Chapter One. It is my premise in this dissertation that, by clarifying the ambiguity underlying moral distress, we can move toward a comprehensive and coherent understanding of the concept—an understanding 20  that is ultimately a prerequisite to the future development of interventions that will support HCPs in the delivery of ethical care. I begin Chapter Two by providing a broad overview of moral distress (MD). In advocating for an understanding of MD that recognizes the mutuality that exists between structures and agents, it is also helpful to sketch a picture of the current landscape of health care delivery. Toward this end, I provide an overview of the health care context in Canada and British Columbia. I then discuss the broader global climate that is reflective of, and impacts decision-making in, health care at a local level, particularly in mental health. I move on to explore the historical background that prompted Jameton to identify moral distress, then proceed to deepen my exploration of the literature noted in Chapter One, by focusing on research on MD in mental health more specifically. In the section that follows the historical background, I investigate MD, keeping the moral agent at the center of the examination. I explore how an inadequate conceptual clarity makes it difficult to distinguish moral distress from other forms of distress, including, but not limited to, burnout4 or compassion fatigue. I also discuss the lack of conceptual clarity with regard to the ideas that make up the definition of moral distress, such as making a moral judgment, the role of action, and the idea of ‘constraints.’ Throughout the discussion, I identify                                             4 Burnout in nursing results from prolonged, high levels of stress at work and leads to a state of emotional, physical, and mental exhaustion, depersonalization of people in their care, and decreased person accomplishment (Schaufeli & Taris, 2005). The term compassion fatigue can result as part of the emotional cost of caring for others, and the resulting behaviours include chronic fatigue, irritability, dread of going to work, and a lack of joy in life (Potter et al., 2010). 21  gaps in our understanding of moral distress and how these gaps have inhibited the development of interventions. I then engage in a discussion of the moral agent, centering on the area of mental health and drawing specifically on research studies examining moral distress in mental health settings. Finally, I sketch a picture of the reciprocal relationship between structures and agents, drawing on an understanding of agents as embodied, and bringing in research from neuroscience and attachment. I conclude this chapter by pointing to the conceptual framing that supports an exploration of MD by focusing on the processes that occur between structures and agents, with the intention of developing conceptual clarity. Throughout this chapter I draw on local and international examples, highlighting the reciprocity between HCPs and health care structures. I also highlight research indicating that structures and agents can influence each other in positive ways. In discussing my research findings in Chapter Seven, I return to the literature reviewed in this chapter to explore the implications in terms of the GT I have developed. Our Current Understanding of Moral Distress The identification of moral distress arose out of a context of rapid changes in health care related to advances in technology, re-structuring of health care delivery, and sociopolitical and cultural changes occurring in the United States (Jameton, 1984). Central to the importance of naming moral distress was a recognition that being thwarted from enacting the values that underpinned health care practice could have significant consequences for HCPs. Identification of MD 22  originated in nursing, and subsequently, much of the research to date has been conducted within the discipline of nursing (Deady & McCarthy, 2010; Pauly et al., 2012; Whitehead et al., 2015; Wocial et al., 2017). However, more recent research on the concept has been conducted across disciplines and within interdisciplinary teams (Burston & Tuckett, 2013; Dodek et al., 2012). As I discussed in Chapter One, an evolution of the definition occurred as researchers worked with the concept and confronted some definitional difficulties. I elaborate on these difficulties later in this chapter. In Chapter One, I showed that understanding moral agency as shaped by context is important for my research. Varcoe et al. (2012) offer the definition of MD as being the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience5 shaped by multiple contexts, including socio-political and cultural context of the workplace environment. (p. 59) However, missing from this definition is the dynamic nature of decision-making given the reciprocal relationship between moral agency and the context in which HCPs work. Throughout this dissertation, I build an argument for the importance                                             5 I make a distinction between how individuals shape, and are shaped by, relationally and through reciprocal relationships. In Chapter One, I described my understanding of “relational” as referring to both interpersonal relationships and how individuals are situated in a connected web of structural relationships in organizations and larger socio-political systems. When I use the term reciprocal, I draw on the idea that people are in a back and forth relationship with their environment and that they influence each other. 23  of understanding MD as a consequence of the reciprocity between structures and agents with the intention of moving toward interventions. I do this by identifying gaps in our understanding of the concept and draw on research from neuroscience, attachment, and embodiment as a potential means for adding to our knowledge. I then reconcile that knowledge with my findings. Contributing Factors and Consequences As our understanding of moral distress continues to evolve, there is growing recognition that the experience may have significant psychological and physiological consequences for HCPs and the health care system (Huffman & Rittenmeyer, 2012; Humphries & Woods, 2016; Rushton, Caldwell, & Kurtz, 2016; Wilkinson, 1987). In an overview of the literature on moral distress by Burston and Tuckett (2013), the authors separated the consequences of the experience into three categories: outcomes toward the self, outcomes toward others, and outcomes toward the system. In describing outcomes toward the self, Burston and Tuckett (2013) found that participants identified feelings of anger related to their inaction or inability to create change. Consequently, some of the experiences nurses described included, but were not limited to, anticipatory dread, diminished self-confidence, and self-doubt; experiences that resulted in feelings of hopelessness, helplessness, a diminished sense of purpose, and professional disillusionment. Outcomes toward others included the expression of anger toward others, and a sense of powerlessness over treatment decisions. In these situations, the nurse risked becoming callous and bitter, or cynical. Finally, 24  in synthesizing research that described outcomes toward the system, Burston and Tuckett (2013) found that when the morally correct course of action became impossible to pursue, nurses took no direct action at all, avoided conflict about the situation, or began to avoid the patient. A further consequence of these outcomes was that in some cases, nurses decided to leave the profession altogether. Evident in this list of outcomes is the negative impact that the experience of MD can have on nurses and other HCPs, patients, and the health care system. Contributing factors to the experience of MD include contextual factors such as sociopolitical contexts that influence funding, health care delivery models that focus on efficiency, and neoliberal ideology that governs health care reform (Rodney, Kadyschuk, et al., 2013; Rodney & Varcoe, 2012; Varcoe et al., 2012). Lack of access to decision-making regarding patient treatment plans and resource allocation, along with hierarchical relationships within health care organizations, and the overall ethical climate, all may contribute to the experience of moral distress (Burston & Tuckett, 2013; Pauly et al., 2009). Prominent examples of lack of access to decision-making that lead to MD include participation in treatment planning in end-of-life care (Heyland et al., 2010; Rodney, 2013). Insufficient inclusion in decisions regarding nursing-staff mix  (when registered nursing staff is reduced) is another example of lack of access to decision-making about resource allocation (Canadian Nurses Association, 2012). Burston and Tuckett (2013) identified individual factors contributing to the experience of MD including character traits such as moral sensitivity; level of 25  authority, such as the HCPs’ position in the organization; and the personal capacity to raise and discuss moral issues. As well, individual values and perceptions of situations such as end-of-life decisions, also contributed to the experience of MD, in that personal values may conflict with unit culture, physicians’ decisions, or family preferences (Burston & Tuckett, 2013). Burston and Tuckett (2013) purpose was to present an overview of the literature on MD to reveal commonalities of factors that contribute to the experience of moral distress. For these authors, the relevance of their synthesis resides in the implications of the effects of MD on nursing and the nursing workforce. For my purposes, the relevance also resides in pointing to the reciprocity that is evident between HCPs and the context, or structures, in which they practice; for example, by examining how site-specific issues such as resources influence care delivery. In focusing on the reciprocity between agents and structure, it has been my intent in this research to move the dialogue on MD beyond implications and toward a more comprehensive and coherent understanding of the concept that is a prerequisite for the future development of effective interventions, as well as prevention of the experience. In order to examine the reciprocity between health care contexts and moral agents, it is helpful to understand the broader sociopolitical influences on health care decision-making, as well as the historical and global dynamics that contribute to the current context. The overview of literature presented above provided the scaffolding for me to examine the reciprocity between structures 26  and agents in our current health care climate. To consider the wider sociopolitical context, I began with the federal and provincial context of health care delivery. Canadian/British Columbia (BC) Health Care Context The delivery of health care services in Canada is increasingly complex and reflective of concerns in health care delivery that exist at a global level. These concerns include questions about how to deliver high-quality health care in a global context of cost constraints and a shortage of skilled health care professionals. Individual countries’ responses to these questions are driven by the sociopolitical culture unique to each country. Indeed, commentators note an overall global trend toward austerity, resulting in overall cuts to health care services that can have a deleterious effect on health at a national population level (Karanikolos et al., 2013; Kentikelenis et al., 2014). The austerity measures implemented to contain health care costs align with the principles of a free market economy, or dimensions of neoliberalism,6 as a mode of governance and as a means of informing policy development (Steger & Roy, 2010). Current policy on health care delivery in Canada reflects this global trend and is underpinned by the messages of cost containment and increasing efficiency (Matier, 2012). Some of the commonly cited factors in the rise of health care costs driving such containment and efficiency measures include increasingly expensive technology,                                             6 Steger and Roy (2010) describe neoliberalism as an economic model built on the ideal of a self-regulating market that arose from classical liberalism in the 1980s. They further explain neoliberalism as best thought of as three intertwined manifestations: 1) an ideology; 2) mode of governance; and 3) a policy package. 27  rising drug costs, an aging population, and increasing chronic illness, a focus on illness rather than prevention, and an overall shortage of skilled health care providers (Canadian Institute for Health Information, 2011; Deloitte Touche Tohmuatsu Limited, 2014). Federally, the Canadian government has responded to these pressures by establishing firm fiscal limits on the amount of money the federal government transfers to the provinces and territories to support health care service delivery (Matier, 2012). There are several concerns with this approach, one of them being that by focusing on the dollar amount that the federal government is transferring to the provinces and territories, the federal government is reducing its role in health care to that of cheque writing (Romanow, Silas, & Lewis). A consequence of this stance may be that the federal government no longer takes the lead in setting national standards for health care delivery and holds the provinces accountable to that standard. This move may have significant implications for equitable access to health care (Browne, 2001; Pauly et al., 2009; Varcoe et al., 2012) in mental health as well as other arenas. A second concern is with establishing firm limits on the Canada Health Transfer (CHT), which creates an overall reduction in the federal portion of money that supports health care service delivery and leaves the provinces and territories endeavouring to deliver health care services with fewer dollars (Romanow, 2002). The significance of the above for my research focus has been the recognition that policy constraints are structuring the practice environment of HCPs and creating the conditions that contribute to HCPs’ experience of moral distress. Restructuring health care 28  delivery to contain costs based on a business model of efficiency has resulted in increased workload for nurses, decreased job satisfaction, increased burnout, increased intention to leave, and increased moral distress (Austin, 2011; Rodney, Kadyschuk, et al., 2013; Rodney & Varcoe, 2012; Shannon & French, 2005). In British Columbia, where my dissertation research took place, such cost containment has been continuing to escalate. For example, a recent Ministry of Health (MoH) Service Plan called for achieving better value in health care through increasing efficiency (Ministry of Health, 2014b), which has continued to reflect policy underpinned by neoliberal tenets. In order to contain costs and achieve efficiency, the provincial government has transplanted models of efficiency from business, such as the Lean Model,7 into the health care system. The recent Service Plan asserts that this restructuring has led to the creation of a “stronger focus on health service planning, policy, analytics, and health service quality assurance. Through this work, we have reduced staffing levels by nearly ten per cent” (Ministry of Health, 2014b, p. 6). From this statement it appears that efficiency has been measured by having fewer people assigned to deliver the same level of service. Focusing on administrative processes and numbers to improve efficiencies is based on the assumption that the quality of the actual care delivered remains unaffected. This has not proven to be the case, as was                                             7 The Lean Model refers to a managerial model that focuses on increasing efficiency and decreasing waste (Kim, Spahlinger, & Billi, 2009). Health care systems in Western countries have applied Lean principles to health care in an effort to constrain cost through creating more efficient processes. D'Andreamatteo et al. (2015) identify that some researchers conceptualize Lean thinking as prioritizing efficient flow over efficient use of resources. 29  evidenced by the Francis Inquiry (2013) from the UK (Hayter, 2013; Musto et al., 2015) to which I now turn. In 2010, a public inquiry was launched in the UK to investigate the broader health care system that included the Department of Health, the local health authority, and the regulatory bodies to determine how significant breaches in duty could have occurred in the Mid Staffordshire Trust (NHS) Foundation Trust (Francis, 2013b). As a cautionary tale, Francis identified a culture that existed within the Mid Staffordshire Trust that focused on “doing the system’s business—not that of the patients” (p. 4). Efficiency based solely on neoliberal reform has the capacity to interfere with HCPs’ abilities to engage with patients in a way that fosters positive health outcomes, and also hampers their ability to practice in congruence with their ethical standards (Austin, 2012; Mänttäri‐ van der Kuip, 2016). Also, HCPs identify the inability to practice according to their Standards of Practice and Code of Ethics as a source of moral distress (Austin, 2016; Austin et al., 2003; Musto & Schreiber, 2012; Peter & Liaschenko, 2013)  On reviewing the current health care context in Canada and British Columbia as I commenced this study, I found a number of experts pointing to the neoliberal ideology imbued in the structures, culture, and policy that guide health care delivery. An examination of the efforts by the federal and provincial government to constrain health care costs reveals how policy shapes the structures in which HCPs deliver care and also contributes to situations (such as short staffing) that lead to moral distress. Yet, although practice is shaped by policy and culture, HCPs are not passive recipients of these influences. Instead, 30  HCPs respond in a variety of ways that may uphold or shift the systems that underpin policy and culture (Rodney, Kadyschuk, et al., 2013). For example, Rodney and Varcoe (2012) described acts of moral resistance, whereby nurses engaged in a variety of actions that ranged from directly advocating for ethical care to bending the rules in order to meet patients’ needs in response to policies that were not in the best interest of the patient. In responding to the structural elements that shape practice, HCPs demonstrate the reciprocity that exists between structures and agents. My purpose in this study has been to make this interplay explicit so that HCPs can make intentional choices about how they want to interact with the institutional structures that shape their practice. That is, I am pointing to the role of action in the experience of moral distress. However, the role of action in the context of moral distress remains ambiguous, and so I investigated this ambiguity when discussing issues regarding conceptual clarity in MD. In order to lay the groundwork for investigating conceptual gaps, it is helpful to review the historical context out of which the concept of MD arose. Historical Context of Moral Distress and Bioethics Elements that contributed to the complexity of health care delivery in the 1970s and 1980s included advances in health care technology that could save or extend life, an increase in the variety of HCPs delivering care, social justice issues related to equity and access to health care and other services, an increasingly informed patient population, changes in the regulation of health care 31  providers, and the increasing domination of health care delivery by a business ethos (Jameton, 1984; Romanow, 2002). These elements, combined with the unique roles and positions nurses occupied in the health care system, gave rise to the experience the Jameton (1984; 1993) identified as moral distress. Conditions within the hospital structure that contributed to the ethical situations nurses faced included hierarchical structures and increasing responsibility with little access to decision-making processes (Jameton, 1977). It is interesting to note that Jameton identified moral distress and these conditions specific to nursing; however, these conditions continue to exist today, as I have noted above, and are experienced within, and between, many of the health care disciplines. Although Jameton situated the experience of nurses within the broader health care context, his perspective of what nurses were experiencing was shaped by his own experiences and education in ethics. Leading up to his introduction of moral distress, Jameton (1984) set the stage by situating health care and bioethics within a historical context. He verbalized a rising sense of crisis in the health care system; according to him, “providers sensed basic value conflicts in conducting their work and became concerned about their ability to express their ideals in it” (p. 1). Evident in the description of the crisis that Jameton observed was an inability on the part of the HCPs to reconcile their values with the rapid changes occurring in health care delivery.  In fact, one of the roles of the ethicist is to create a space for the discussion of values within health care (Arras, 2010; Jameton, 1984; Wolpe, 32  2000). However, a critique of bioethics is the disconnect that exists between ethical theory and the actual practice issues faced by HCPs (Arras, 2010). This critique may have some consequences for the definition of moral distress as I view it, which is as tripartite. By tripartite I mean that the definition can be broken down into three parts: a) making a moral judgment, b) failure to take action, and c) institutional constraints. The lack of conceptual clarity underpinning each part of the definition may partially result from the ambiguous connection between ethical theory and clinical practice. Indeed, in tracing the rise and evolution of bioethics within health care, critiques of bioethics focus on the utility of applying ethical theory to the situations faced by HCPs (Arras, 2010; Borry, Schotsmans, & Dierickx, 2005; Wolpe, 2000). One of the critiques is related to the disconnection of high-level ethical theory from the situations and contexts of bedside care to direct action (Arras, 2010). High-level ethical theory refers to theories that provide justification for broad ethical concepts, for example, freedom or justice (Arras, 2010; Jameton, 1984). Specific to the critique of bioethics is the concept that high-level ethical theory is not sufficient for examining the messy reality of the immediate context in which specific ethical situations arise, as is the case with the experience of MD (Rodney, Burgess, et al., 2013). For ethical theory to have more practical application and utility at the bedside, an acknowledgement of the structural features of the health care organization is necessary (Arras, 2010; Jameton, 1984). I believe that high-level ethical theory underpins Jameton’s definition of moral distress and continues to contribute to a lack of conceptual clarity. For 33  instance, underpinning the concept of making a moral judgment may include an assumption of the moral agent as an independent and self-determining individual (Rodney, Kadyschuk, et al., 2013; Sherwin, 1998). In his book Nursing Practice, the Ethical Issues (1984), Jameton is clear that he is offering a philosopher’s approach to bioethical issues and I propose that his definition of moral distress reflects the strengths of—but is simultaneously confined by—his perspective (Hanna, 2004). In Chapter One, I proposed that the definition of moral distress was predicated on three main assumptions: a) that nurses had made a moral judgment, b) that they did not act on that moral judgment, and c) that inaction was related to institutional constraints. In identifying that nurses made a moral judgment, Jameton identified that “one knows the right thing to do…” (p. 6). Although Jameton acknowledged the broader sociopolitical contexts that shaped nursing action, his explanation of moral reasoning fell within the tradition of moral philosophy. In describing the importance of moral reasoning, Jameton stated that a person’s ability to reason and give reasons are central to determining ethical responses (Jameton, 1984). In providing his explanation of moral reasoning, in fact, Jameton was careful to include the importance of intellectual and emotional resources to the process. Nonetheless, I argue that, in taking a solely philosophical approach to moral reasoning and making a moral judgment, Jameton assumes that intellectual and emotional capacities are corralled by our cognitive abilities to aid in making a moral judgment, thereby overlooking the possibility that moral judgments may 34  also involve different processes when they are made within complex organizational contexts. Thus, in defining moral distress from the perspective of a philosopher and a bioethicist, Jameton drew on moral theory to explain an embodied experience that was located contextually in the broader sociopolitical and cultural context, as well as in the immediate context of the situation. While this conceptual framing was a landmark achievement at the time, it is my contention that the moral theory Jameton drew on was not fine grained enough to account for the encompassing experience of moral distress described by nurses and other health care providers—including the participants in my study. His theorizing was also not adequate to capture the differences in the experience that occur across health care specialties. Over the past 30 years, particularly the past 10, researchers (Carse, 2013; Deady & McCarthy, 2010; Fourie, 2015; Mack, 2013; Mänttäri‐ van der Kuip, 2016; Ohnishi et al., 2010) have attempted to illuminate the finer details related to local contexts and also capture contributing factors specific to health care disciplines and health care practice contexts. These researchers have, overall, based their studies on Jameton’s (1984) original definition. In doing so, they recognize difficulties with the definition and have made necessary, but not yet sufficient, progress in clarifying the concepts that underpin the definition of moral distress (Morley et al., 2017; Musto et al., 2015; Pauly et al., 2012; Thomas & McCullough, 2015). 35  Moral Distress and Reciprocity Moral distress is an individual response to situations that result from organizational, cultural, and sociopolitical contexts that frame the situation. Until we understand the processes through which the reciprocity between structures and agents occurs, we will perpetuate the notion that the moral agent acts and thinks independently of the circumstances that shape them. In taking this position, we (at least implicitly) hold the moral agent primarily responsible for the experience of MD. Austin et al.’s (2003; 2005; 2008) work highlights the reciprocity8 that is not just at an organizational level, but is also at a societal level, as societal expectations shape the moral obligations of the HCPs. Structural reciprocity extends beyond the level of healthcare organizations. Expectations of HCPs are also shaped at a provincial level through the regulatory bodies that define Standards of Practice, and at a federal level by the professional bodies that establish the professional Codes of Ethics (Austin, 2016; Peter & Liaschenko, 2013). In order to move toward better conceptual clarity and gain an understanding of the reciprocity that exists between structures and agents, I have organized the material above, and the remainder of this chapter, by separating structural issues that contribute to MD from the impact of the experience on                                             8 Reciprocity in relationships in the health care system are part of the is-ought gap, wherein relationships in health care ought to be reciprocal. Quite often, relationships are not reciprocal, causing power imbalances that contribute to HCP disempowerment.  36  moral agents. In doing so, my intention is to move beyond the limitations inherent in Jameton’s original definition. In the next section I therefore explore what is known about the sociopolitical elements that have contributed to moral distress in mental health care specifically. This review also sets the stage for the analyses of my study findings in Chapter Five. Moral Distress in Mental Health Care In Canada, 20% of the population is expected to struggle with mental health issues each year. However, globally, as well as nationally, services for mental health are considered to be inadequate (Mental Health Commission of Canada, 2018; World Health Oganization, 2013). As well, many countries, including Canada, face a shortage of HCPs serving mental health populations (Kakuma et al., 2011; Smith & Khanlou, 2013). Canada, along with other industrialized countries, is looking for a way to contain rising health care costs by ensuring an effective and efficient system in health care overall, including mental health care. Along with cost containment and a shortage of skilled HCPs, the social determinants of health also play a significant role in shaping the discussion on the most cost effective way to deliver mental health care services. The Mental Health Commission (MHC) (2012) developed a multipronged approach to mental health care delivery in Canada that included attention to the social determinants of health. The plan advocates for a recovery approach that includes access to community-based services, peer support, supported housing, education and 37  employment (Mental Health Commission of Canada, 2012). The development of a national strategy for mental health care took place in a staged process that involved significant consultation with stakeholders across Canada. It also took place against the backdrop of the neoconservative reforms to health care discussed in Chapter One, and as such, it is difficult to know if the federal government will hold the provinces/ territories accountable for implementing the strategies in the MHC9. In BC, the MoH published a mental health plan that was intended to take a broad view of mental health and include health promotion and prevention across and individual’s lifespan (Ministry of Health Services & Ministry of Child and Family Development, 2010). While acknowledging the importance of attending to the determinants of health through policy, the language of the mental health plan takes up a similar message of cost constraint seen in the federal document, CHT (Matier, 2012) and the MoH Service Plan (Ministry of Health, 2014b). Focusing on efficiency, the recommendations are concentrated on making more “effective” use of existing services, without questioning the adequacy of current service levels. Although it is difficult to get an exact picture of the adequacy of mental                                             9 The Mental Health Commission of Canada (MHCC) was established in 2007 by Health Canada as an arms length non-profit organization with a specific mandate, for a set period of time--10 years. The mandate included the creation of a national mental health strategy, to reduce stigma, and advancing knowledge exchange in mental health (Mental Health Commission of Canada, 2016). An evaluation of the MHCC acknowledges the effectiveness of the Commission, along with an ongoing need for further efforts to address the mental health needs of the population (Health Canada & Public Health Agency of Canada, 2016) 38  health services in BC, in Metro Vancouver alone, the Vancouver Police Department has expressed significant concern regarding the increase in police contact with people struggling with mental health issues, and has called for increased services for this population (Thompson, 2010; Vancouver Police Department, 2013; Wilson-Bates, 2008). Such lack of adequate resources necessary to provide care according to professional Standards of Practice has been identified as a structural element that contributes to MD (Austin et al., 2003; Rodney, Kadyschuk, et al., 2013) in HCPs. Moral Distress and Patient Care in Mental Health The key to working with patients in mental health is the development of the therapeutic relationship, for it is the medium through which all interventions are delivered (Gardner, 2010; Registered Nurses Association of Ontario, 2002). Research on patient outcomes in mental health supports the notion that the therapeutic relationship contributes improved health outcomes for the patient (Cutcliffe et al., 2015; Hiskey, 2012; Peplau, 1952). As well, researchers conducting studies to explore the therapeutic relationship with nurses working in mental health identify major themes critical to building a therapeutic relationship as entailing trust, power, mutuality, self-revelation, congruence, and authenticity; all in the context of maintaining professional boundaries (Gardner, 2010; Welch, 2005). The themes identified by the participants of these studies suggest that an element that contributes to developing the therapeutic relationship is time. Commentators are noting that the health care system needs to enable processes 39  that demonstrate the importance of the therapeutic relationship and the HCP needs to maintain a willingness to engage with the patient at the center of their care (Austin et al., 2003; Gardner, 2010; Registered Nurses Association of Ontario, 2002). For example, in a study by Austin et al. (2003), nurses identified care situations that they found morally distressing. Lack of time emerged as a primary contributor to the experience of moral distress. The lack of time for patient care was attributed to changes in the health care system. Although these changes were not elaborated, the stories told by participants indicated that the changes were a result of attempts to constrain health care costs, which resulted in increased workloads and lack of access to the basic resources necessary to provide care. Participants described how lack of time interfered with developing a therapeutic relationship and being able to provide safe, ethical care. This resulted in nurses feeling disconnected from their patients and each other, and in their failure to treat patients with dignity and respect. The participants in this study described examples of emotional avoidance10 of the situations that caused moral distress. Avoidance behaviour as a consequence of moral distress was one of the findings by Burston and Tuckett (2012) in their overview of the literature on                                             10 De Villers and DeVon (2012) describe nurse avoidance behaviours as more than the absence of a physical presence, stating that it is a conscious effort to “avoid thinking about an event or reminder of an event” (p. 594). Avoidant behaviours include physical and psychological avoidance that includes the absence of physical and verbal contact with the patient, such as, lack of time spent with the patient, limited eye contact, decreased physical proximity, and negative verbal mannerisms.  40  moral distress and may have consequences for patient outcome, such as failure to rescue. Failure to rescue (FTR) is a nurse sensitive measure that can be used as part of evaluating the quality of care provided in a hospital (Clarke & Aiken, 2003; Schmid et al., 2007). FTR refers to the “inability to save a patient’s life after the development of a complication” (Schmid et al., 2007, p. 188). As a nurse sensitive outcome, FTR has been tied to staffing ratios, and was initially studied only in surgical units, but research has since extended to medical units, ICUs, and perinatal areas (Clarke & Aiken, 2003; Schmid et al., 2007; Simpson, Lyndon, & Ruhl, 2016). Nurse surveillance underpins the connection between staffing levels and FTR, and includes initial and ongoing assessments of the patient in order to recognize changes in the patient’s health status. Another element of FTR, once a potentially serious complication has been noticed, is that the nurse needs to mobilize hospital resources quickly (Clarke & Aiken, 2003). Along with staffing levels, avoidance of a patient due to the experience of moral distress may also contribute to FTR. Avoidance of patients and FTR are particularly salient in acute care mental health settings where time constraints interfering with the development of the therapeutic relationship have been identified as contributing to the experience of MD. Increasingly, mental health patients are recognized as having significant medical comorbidities leading to a decreased life expectancy (Walker, 2015).  In another study with psychiatric nurses, Ohnishi et al. (2010) examined the relationship between moral distress and burnout in a Japanese context; they 41  also found that low staffing correlated with moral distress and burnout. More specifically, Ohnishi et al. (2010) also found that the frequency and intensity of moral distress correlated positively with higher levels of cynicism and exhaustion. Interestingly, the authors noted that nurses who took care of more patients reported feeling less exhausted. Taken at face value, this finding appears to contradict earlier findings linking moral distress to low levels of staffing. A potential explanation for this finding is that participants working with more patients were using psychological coping strategies such as moral disengagement in order to protect themselves from any distress they may have felt (Deady & McCarthy, 2010; Rodney, Kadyschuk, et al., 2013). A commonality between both studies was that a lack of external resources led to inadequate care, or patients being treated with a lack of dignity; both situations that created moral distress for many participants. One of the gaps in our knowledge of moral distress in mental health care is a full understanding of the impact of the experience on the quality of patient care. This includes understanding the influence of avoidance behaviours (Burston & Tuckett, 2013), moral disengagements11 (Rodney, Kadyschuk, et al., 2013), and the impact of moral distress on the formation of the therapeutic relationship in psychiatric settings (Austin et al., 2003). Given that the therapeutic                                             11 Rodney, Kadyschuk, et al. (2013) draw on Bandura’s social cognitive theory to explain, what they describe as “some nurses’ shifting moral identity” (p.171). Bandura argues that moral disengagement is a mechanism that individuals use to avoid self-condemnation when they engage in behaviours that do not align with their own moral standards (Bandura, 2002). For an in-depth explanation of moral disengagement and how it may apply in healthcare settings, I refer readers to Bandura, 2002, and Rodney, Kadyschuk, et al. (2013). 42  relationship is foundational to the delivery of interventions in mental health, anything that inhibits the development of that relationship may interfere with fostering positive patient outcomes. Clarifying the relationship between moral distress, burnout, and FTR in mental health care will aid in identifying ways to support HCPs. I examine the relationship between these concepts and the quality of patient care in Chapters Six and Seven. Summary of External Structures that Shape the Context of Care  I have outlined above some of the historical and current health care structures that shape health care delivery. It is not a coincidence that Jameton identified moral distress in the mid-1980s, at the same time that neoliberal tenets gained political traction and began to influence government policy regarding health care in the early 1970s (Browne, 2001; Steger & Roy, 2010). My purpose in this section has been to situate my study by providing an overview of moral distress and the historical context from which it arose. The issues that have existed historically in health care and that gave rise to a crisis in health care professionals’ ability to express their values continue to exist today. Global discourses of fiscal restraint and the application of business models to health care systems have created practice environments that can conflict with core values and Codes of Ethics of HCPs (Austin, 2011). One of the consequences of this values conflict has been the experience of moral distress. Having outlined some of the structures that shape health care in this section, I examine the moral agent in the context of these structures in the next 43  section. I do this by reviewing the research on moral distress that has been focused on HCPs’ experience of moral distress in an effort to better understand the concept. Initially, I draw on the research across health care specialties; however, in order to better understand how the experience impacts HCPs in mental health, I move on to draw on studies conducted in acute care psychiatric units. Gaps in Our Knowledge: Reciprocity and The Moral Agent In this section of the chapter I further examine the role of the HCP as the moral actor in moral distress. Throughout, it is my premise that in order to support HCPs to fulfill their moral obligations to those they care for, we need to understand how reciprocity between structures and agents potentially occurs. There has been growing speculation regarding the potential moral consequences of health care delivery underpinned by a drive for efficiency which has led to ongoing and rapid restructuring of the health care system (Shannon & French, 2005). Some of these consequences include moral disengagement and moral residue12 (Rodney, Kadyschuk, et al., 2013; Webster & Baylis, 2000). Other negative ramifications linked to moral distress include burnout, compassion fatigue, patient avoidance, and workforce retention issues (De Villers & DeVon,                                             12 Moral residue is a term used by Webster and Baylis (2000) to describe the experience where, in the face of moral distress, “we have seriously compromised ourselves or allowed ourselves to be compromised” (p. 218). These moments have a powerful, and lasting, effect on individuals because the moments have threatened, or led to, a betrayal of deeply held values and beliefs. I direct readers to Webster and Baylis (2000) for a comprehensive reading on moral residue. 44  2012; Maiden, Georges, & Connelly, 2011; Wilkinson, 1987). I argue that these consequences are not solely a result of health care structures and policies impinging on HCPs; instead, they are a result of the interaction between HCPs and these structures. In what follows, I review the literature on moral distress in relation to the impact of the experience on moral agents as well as the responses of HCPs (moral agents) and their subsequent actions. This includes a discussion of the consequences of these actions for health care organizations and for patient care. Much of the research on moral distress reflects the nursing profession from which it arose; as such, most of the early research studies I draw on are specific to nursing. More recent research has been published, and includes multidisciplinary or interdisciplinary studies in an attempt to establish a more complete understanding of the phenomenon. I draw on a range of literature to try and capture the extent of the consequences and identify the gaps. I will return to some of the literature in Chapter Six as I analyze my own findings. Relationship between the Code of Ethics and Moral Distress in Mental Health Care That nursing is a moral endeavour has been well argued elsewhere in the literature (see, for example, Austin 2011, 2012; Corley, 2002; Doane & Varcoe, 2013); however, the influence of a Code of Ethics and Standards of Practice on moral distress is not clear. An example of reciprocity between structures and moral agents is in the development of the moral identity of nurses. Peter and Liaschenko (2013) re-examine moral distress using a feminist lens. In doing so, 45  they highlight the moral construction of the nursing identity rooted in historical and relational contexts, stating: The identity of a “nurse” is a social construction. It is generally associated with being a woman, a kind caregiver, an assistant to the physician, and a virtuous healer. These constructions might not reflect the work, gender, or character of many nurses. Yet, this nurse identity is something nurses encounter and perhaps embrace as they begin their education and work. Nurses participate in this construction by the roles they assume and how they describe themselves (p. 339). The quote above demonstrates the reciprocity that exists between social structures, such as government agencies and professional organizations, and individuals who take up the profession. Professional Codes of Ethics and Standards of Practice are a part of the narrative that shapes socialization into the profession and defines the relationships and responsibilities (Peter & Liaschenko, 2013). In their research with psychologists, Austin et al. (2005) found that the experience of moral distress was grounded in a sense of professional integrity. The authors identify necessary perquisites of moral distress as including awareness of ethical issues and accepting moral responsibility. Austin et al. (2005) argue that moral responsibility or obligation are embedded in the role of being a professional and that a threat to professional integrity occurred when psychologists, for example, perceived they were unable to fulfill their moral 46  obligations. Similarly, Peter and Liaschencko (2013) claim that moral distress may arise due to constraints on moral agency and an inability to live up to socially constructed professional responsibility that is also taken up by individual agents. Further research with HCPs in mental health care revealed that, in describing their experience of moral distress, HCPs raised concerns about meeting their moral obligations in reference to their professional Standards of Practice and Code of Ethics (Austin, 2011, 2012; Austin et al., 2005; Musto & Schreiber, 2012). These moral obligations are often connected to notions of diminishing suffering, patient advocacy, and safety, which are deeply embedded values in our understanding of what it means to care for the vulnerable other (Austin, 2012; Corley, 2002; Musto & Schreiber, 2012; Peter & Liaschenko, 2013). A professional Code of Ethics arises out of the very discipline that it guides practice for and embodies these same values. As such, it is a guide to the reciprocity that should exist between moral agents and structures. HCPs are legally bound to practice according to the standards set by their regulatory body (Ministry of Health, 2014a), however, HCPs are also held accountable to societal expectations. For example, a study by Austin et al. (2008) found that psychiatrists experienced moral distress as a result of attempting to balance responsibility to their individual patients according to the Hippocratic principles with the expectation that they will protect society from deviant behaviour. Legal accountability and societal expectations may add to the sense 47  of moral obligation held by a HCP, and can contribute to the intensity of moral distress when HCPs are unable to balance these tensions.  Multidisciplinary studies indicate that, while moral distress is common across disciplines, the situations that give rise to the experience, along with professional responses, differ (Austin et al., 2008; Dodek et al., 2012; Hamric & Blackhall, 2007). For example, in their research on moral distress in mental health, Austin et al. (2003; 2005; 2008) found that nurses communicated that lack of time to develop a therapeutic relationship with their patient contributed to experiencing moral distress (Austin et al., 2003). Psychiatrists identified that trying to balance ethical responsibility to their patient with their obligation to protect society contributed to moral distress (Austin et al., 2008). Appreciating these distinctions may shed light on professional differences in understandings of moral obligations. The importance of the role of a professional Code of Ethics and practice standards may apply across all areas of health care delivery; however, it is also necessary to understand how societal expectations specific to the different areas influence moral distress. It is important to note that research on moral distress in health care has been confined to regulated professions. Conducting research with unregulated HCPs may actually help delineate the role of Standards of Practice, which is one of the structural elements that shape moral distress. As well, conducting research on moral distress with patients and family would provide depth to our understanding of the concept. Nevertheless, for my purposes, I confined this study to regulated health care professionals. 48  An Evolving Definition Making a moral judgment. Wilkinson (1987) was the first researcher to specifically examine the concept of moral distress after Jameton established it in the literature. In developing her study, Wilkinson drew on key areas of literature that foreshadowed the struggles that exist with the definition that exist today. As I noted above, Jameton’s definition of moral distress was likely underpinned by theoretical concepts rooted in moral philosophy, Wilkinson was also the first researcher to adjust the definition to reflect the participants’ actual experience based on inductive research rather than deductive reasoning. Wilkinson (1987) defined moral distress as “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision” (p.16). Since this time, researchers have continued to modify the definition in order to account for some of the ambiguity that emerged in their research (See the table in Appendix A for an overview of the evolution of the definition). In incorporating the affective experience of participants, Wilkinson moved away from theoretical moral decision-making frameworks rooted in cognition and toward contemporary views of moral development. One prominent theory of moral reasoning was based on the work of Lawrence Kohlberg, who presented a model of moral development based on a staged progression (Kohlberg, 2008/1963). In Kohlberg’s model, based on an ethic of justice, the highest stage of moral development reflected moral decision-making based on the application of moral principles to determine the correct action (Kohlberg, 2008/1963). 49  Participants demonstrated their moral reasoning processes by working through hypothetical situations posed by Kohlberg and his research team. Carol Gilligan, a student of Kohlberg and others later critiqued his work as being explicitly male gendered (biased), as well as influenced by the sociopolitical context of the day (Flanagan, 1982; Gilligan, 1982; Walker, 2004). Gilligan presented her own, equally gendered, model of moral development grounded in a contextual and relational approach to moral reasoning based on an ethic of care (Gilligan, 1982). The next decade saw a debate polarized along the line of gender that did little to advance our understanding of how moral reasoning could be moved to moral action. It is against this backdrop that Wilkinson situated the moral reasoning of HCPs within organizational structural processes (Wilkinson, 1987); see also Rodney, 1997. In the mid-1990s, another shift began in the field of moral psychology that tapped into research findings from neuroscience. Although still very much a developing field, neuroscientists are beginning to shed light on the processes that take place in the brain as participants engage in moral reasoning (Damasio, 2007; Decety, Michalska, & Kinzler, 2011; Greene, 2014; Moll & de Oliveira-Souza, 2007; Moll, de Oliveira-Souza, & Eslinger, 2003; Narvaez, 2014). It has become apparent that moral decision-making is a complex process that involves an interplay between morality, brain structures, and human experiences, as well as “environmental influences, such as early experiences, formal education, and ordinary interpersonal transactions” (Moll et al., 2003, p. 304), that shape the structures of the brain used in moral reasoning.  50  My point here is that our understanding of moral reasoning at this moment in time is far more nuanced than when Jameton introduced the concept of moral distress. In order to understand how HCPs make moral judgments and turn these judgments into moral action in an organizational context, we need to incorporate knowledge from neuroscience and moral development. Understanding the process of moral reasoning could help researchers develop interventions that support HCPs as they navigate organizational barriers to moral action. The concept of constraints. Wilkinson also showed that constraints could be actual or perceived, and could be external or internal to the participant. Austin et al. (2005) took this speculation further and connected the lack of moral action to an internal failure that may have lasting consequences for the individual. In locating constraints solely within the realm of the organization, Jameton inadvertently perpetuated the belief that nurses were powerless to act in the face of organizational and hierarchical authority. This, in fact, was not true; something that he acknowledged when he further refined his definition to include initial and reactive moral distress (Jameton, 1993). He encouraged nurses to take on the “the perspective of the responsible actor” (p. 547; original italics), to help delineate the extent of professional responsibility in an organizational setting. Taking up the role of a responsible actor instead of the perspective of a victim powerless to create change, is an example of how internal constraints may either inhibit or support a person to take action. In this way, our understanding of constraints moves away from determining the location and toward examining how the interaction between the environment and HCP generates a particular 51  response from the agent. This view of constraints may ultimately provide a more accurate picture of the kind of interventions that will help support HCPs as they enact their moral agency. Nonetheless, it remains understudied, and has therefore been an area of focus for my dissertation research, and is reflected in my findings in Chapters Five, Six, and Seven. The role of action. Central to the experience of moral distress is the role of action or inaction; the accompanying assumption is that taking action will alleviate the experience of moral distress. This has not proven to be the case, as researchers in moral distress clearly identified situations in which HCPs took action either directly or indirectly without experiencing relief from moral distress. In several studies, researchers recount instances of participants taking action in morally distressing situations, only to discover that the repercussions of their action caused further distress (Austin et al., 2003; Musto, 2010). For example, some participants have spoken up regarding ethical concerns only to find themselves ostracized from the health care team (Musto & Schreiber, 2012). Another problem with the idea of taking action in moral distress is the question of what counts as action. Importantly, Wilkinson was also the first to speculate about, and develop, a substantive theory of moral distress that linked the long-term consequences of the experience on nurses to the quality of patient care (Wilkinson, 1987) they were able to provide. The substantive theory began to point to the reciprocity that existed between structures and agents as it tracked nurses’ responses and actions from the inception of the experience through coping strategies to the resulting consequences on the nurse and patient care. 52  Wilkinson (1987) acknowledged that the impact of effective coping strategies on nurses was that they maintained wholeness and engaged in compensating behaviours with their patients. In contrast, ineffective coping resulted in nurses avoiding their patients, feeling powerless and overwhelmed, and leading the nurse to leave the unit or the profession (Wilkinson, 1987)(Wilkinson, 1987)(Wilkinson, 1987)(Wilkinson, 1987)(Wilkinson, 1987)  Wilkinson attempted to demonstrate the dynamic nature of the process as the nurse accessed coping strategies to rectify a situation. Thus, Wilkinson was indicating that moral distress is not always an immediate reaction to a specific situation but may also occur over time as the HCP reflects on the situation or an ongoing practice (Musto, 2010; Musto & Schreiber, 2012). The idea of frequency of exposure to morally distressing events has been correlated to increasing intensity of the experience and moral residue (Epstein & Hamric, 2009). The line between coping strategies, such as avoidance when the situation is ongoing, and actions to resolve the situation, is ambiguous. Although Wilkinson (1987) did not offer a critique of Jameton’s definition, she pointed to moral theorists who gave weight to the affective dimensions of moral reasoning and who opened up the space between moral reasoning and moral action for questioning. It is only in the past ten years that significant critiques of the definition have arisen (for example, see Hanna, 2004; Johnstone & Hutchinson, 2013; McCarthy & Deady, 2008; Morley, Ives, Bradbury-Jones & Irvine, 2017; Musto, Rodney & Vanderheide 2013; and Varcoe et al., 2012 for a summary of the critiques). Researchers have identified significant gaps within the 53  definition and have subsequently made slight adjustments; nonetheless, the early definition remains widely used as the foundation for research seeking to further our understanding of the concept (see, for example, Carse, 2013; Hamaideh, 2014; Mason et al., 2014).  Until recently, one of the few measurement tools available to assess the extent of moral distress was the Moral Distress Scale (MDS) (Hamric, 2012). The MDS was based on Jameton’s conceptualization of moral distress and has been widely used as a measurement tool in research studies that could directly measure the construct of moral distress (Hamaideh, 2014; Karanikola et al., 2014; Ohnishi et al., 2010; Zuzelo, 2007). While empirical measurement of the concept has been an important potential means of influencing practice and policy, retaining the original definition has not moved our understanding forward in any significant way. My intent in examining moral agency in this dissertation was to bring further clarity to the role of action in the concept of moral distress, and explore the elements that influenced constraints on moral agency in ethically challenging situations. It has been my conviction that the findings from this study could then be used to inform the development of a measurement tool that accurately reflected the experience of moral distress. Impact of Moral Distress on HCPs Notwithstanding the evolving nature of our understanding of the definition of moral distress, there is general agreement among researchers that moral distress has a significant impact on HCPs, and consequently on patient care, as 54  well as health care organizations (De Villers & DeVon, 2012; Pauly et al., 2009). Wilkinson conducted in-depth interviews with 26 participants from the nursing profession who self-identified as having experienced moral distress. Her participants identified significant impacts on their physical, psychological and emotional health that included loss of self-worth, an effect on personal relationships, psychological effects, nightmares, palpitations, headaches and diarrhea (Wilkinson, 1987); subsequent research has supported, and added to, these findings (Austin et al., 2005; Corley, 2002; Elpern, Covert, & Kleinpell, 2005). However, moral distress need not have a negative outcome for HCPs, as wrestling with values and value conflicts may help clarify the moral boundaries of care (Hanna, 2004; Webster & Baylis, 2000). Integral to fostering processes that support the potential positive benefits of the experience is the understanding of the role of reciprocity between the health care environment and HCPs in the choice of coping strategies to work through moral distress. As HCPs try to manage these negative and uncomfortable affective states, they engage a variety of coping strategies with varying levels of success (Austin et al., 2005; Deady & McCarthy, 2010; Musto & Schreiber, 2012; Wilkinson, 1987). Coping strategies for moral distress identified in the literature include, but are not limited to, talking to a supervisor and/ peers; self-reflection; reacting by minimizing, trivializing or rationalizing the situation; and working part-time (Deady & McCarthy, 2010; Musto & Schreiber, 2012; Webster & Baylis, 2000; Zuzelo, 2007). The choice and success of these strategies are also reflective of the interplay between the internal structures of 55  the participant and the external environment. For example, when HCPs chose to bring ethical issues forward to their supervisors, their belief in the effectiveness of this strategy was based on the individual’s past experience of bringing up similar issues with their supervisor (Musto & Schreiber, 2012).  Several researchers discuss the importance of health care organizations being receptive to, and providing the space and time for, discussion (Huffman & Rittenmeyer, 2012; Mitton et al., 2010; Rodney, Buckley, et al., 2013; Ulrich, Hamric, & Grady, 2010). Understanding how the external environment influences individual choices regarding coping strategies, as well as how individual internal structures allow some individuals to pursue strategies that support an ethical environment, can ultimately provide a foundation for advancing interventions. On the basis of my analysis of my dissertation findings, in Chapter Six, I discuss organizational resources and processes that influenced participants’ choice of strategies as they navigated ethical challenges. In Chapter Seven, I put forward suggestions for how the organizations can support the enactment of moral agency. If the practitioner is unable to resolve the experience of moral distress, the consequences may include moral residue (Webster & Baylis, 2000), moral disengagement (Rodney, Kadyschuk, et al., 2013), and/or a decision to leave the area of work or even the profession (Dodek et al., 2012; Hart, 2005). Moral residue refers to the lasting impact that resides within an individual following an experience where he or she was seriously morally compromised (Webster & Baylis, 2000). The sequelae of moral residue can be that it helps the individual 56  clarify values for when future situations arise. Alternatively, the individual may become disconnected from his or her values, becoming a “moral chameleon” (Webster & Baylis, 2000, p. 224). Both outcomes have consequences for the organizations in which the moral agents work. In the first case, the person can help the organization maintain a high-level of moral commitment to patient care. In the second case, the person becomes desensitized to wrongdoing or constantly shifts his or her values to align with the situation at hand, which may lead to errors in judgment with regard to clinical care. Exploring related concepts. Other possible consequences for HCPs that have been linked to moral distress are burnout and compassion fatigue. Burnout is a recognized syndrome characterized by exhaustion and cynicism (Maslach, Schaufeli, & Leiter, 2001; Robinson, Clements, & Land, 2003), and compassion fatigue describes an inability to care for others related to emotional exhaustion as a result of secondary exposure to high stress situations (Maiden et al., 2011). Both of these phenomena have been linked to moral distress and have similar consequences with regard to patient care, including avoidance (Maiden et al., 2011; Robinson et al., 2003). Maiden et al. (2011) set out to examine the relationship between compassion fatigue, moral distress, perceptions about medication errors (as an indicator of unsafe practice and work environment) and nurse characteristics. They found a positive correlation between compassion fatigue and moral distress. They also identified environmental issues such as blame and punitive administrative responses that led to strong negative effects—for example horror, devastation, and fear—that contributed to a lack of reporting 57  of medication errors. In making this connection, the authors highlight the interplay that exists between external environmental structures and the internal environment of the HCP. As I stated at the beginning of this section, there is general agreement that the experience of moral distress can have a harmful effect on HCPs. Likewise, researchers have also pointed out the negative impact on moral distress on the organization related to turnover, retention, productivity of employees, and, significantly, on patient care (Mitton et al., 2010). Relationship Between Moral Distress and Patient Care The purpose of Wilkinson’s (1987) study was to develop a substantive theory about the relationship between moral aspects of nursing practice and the quality of care. For her study, Wilkinson assumed that, as nursing was a moral profession, acting in a way that contradicted the values of nursing would have consequences that impact patient care. Participants articulated both positive and negative strategies for managing the situations that led to moral distress. Successful coping strategies prompted participants to compensate their patients, providing extra emotional support and being attentive to their physical needs , to make up for the situation. Instances of unsuccessful coping led participants to avoid the patient who was a part of the situation that created moral distress (Wilkinson, 1987). The concept of avoidance is significant to the quality of patient care and is connected to moral distress both directly and indirectly. As is seen in Wilkinson’s study, and supported in subsequent research, HCPs acknowledge using avoidance of the patient or situation that led to moral distress as a 58  protective mechanism against further distress (De Villers & DeVon, 2012; Gutierrez, 2005; Wilkinson, 1987, 1989). Avoidance can take different forms, including asking not to take care of a specific patient, distancing from the patient, not engaging with the family, or even avoiding work altogether (Gutierrez, 2005; Musto & Schreiber, 2012). The study by De Villers and DeVon (2012) demonstrated a correlation between the experience of moral distress and avoidance in both critical-care and noncritical-care nurses. FTR is based on the notion of a preventable death in health care (Clarke & Aiken, 2003), and was initially used as a measure of hospital performance that measured HCPs’ response to patients following the development of complications postsurgery (Schmid et al., 2007; Trudeau, Clarke, & Aiken, 2003). As a measure of performance levels in hospitals, the concept had been linked to staffing levels, education level of nurses, and skill-mix; however, understanding how ethical elements may contribute to FTR has been overlooked. Central to FTR is not recognizing the deterioration in the status of a patient and instituting the appropriate interventions in a timely manner. Interestingly, in several studies on moral distress, nurses do not identify a change in the quality of care even though they describe behaviours of avoidance (Gutierrez, 2005; Wilkinson, 1987). This raises the concern of whether or not nurses struggling with moral distress recognize if, or when, the quality of the care he or she provides is not adequate to meet the needs of the patient. The causal relationships between the quality of patient care and levels of moral distress have not been fully explored. Yet, there is some indication that when HCPs morally 59  disengage, the quality of healthcare delivery deteriorates (Rodney, Kadyschuk et al. 2013; Rodney, Buckley et al. 2013). A further consideration for my study on moral distress has been the relationship between avoidance and FTR in mental health. In research on moral distress specific to mental health, nurses described coping strategies that included avoidance and distancing themselves from the source of the problem (Deady & McCarthy, 2010; Musto, 2010). Avoiding a difficult patient due to moral distress may result in missing the deterioration of the status of the patient leading to FTR. The main question in a mental health setting, then, is what are the consequences of missing the deterioration of a patient’s status? The care of mental health patients in acute care settings has become more complex due to higher acuity and increased comorbidity related to diabetes, dyslipidemia, hypertension, and obesity (American Psychiatric Nurses Association, 2012). I was unable to find any literature on FTR in the context of mental health settings. Given that there is also limited research on moral distress in mental health, further studies such as the one I have undertaken in this dissertation, are necessary in order to understand the potential consequences of moral distress for HCPs and the quality of patient care. Moral Distress Research in Mental Health As our knowledge of moral distress has increased over the past 30 years, and increasingly, there have been calls to move toward effective interventions (American Association of Critical-Care Nurses, 2008; Bell & Breslin, 2008; 60  Hamric, 2012; Pendry, 2007; Rodney, Kadyschuk, et al., 2013). This call for interventions has recently led three ethics journals13 to devote full issues to the topic (Musto et al., 2015). Nevertheless, despite the growing interest in moral distress, few studies have been conducted in mental health care (Austin et al., 2003; Deady & McCarthy, 2010; Nuttgens & Chang, 2013; Ohnishi et al., 2010). The studies that have been conducted in mental health care reveal similar findings of moral distress in relation to emotional, physiological, and psychological consequences. As well, research participants in mental health care express similar strategies for managing the experience, including intentions to leave the health care unit or the profession (Musto, 2010). Having said this, as can be seen in the literature reviewed above, there remain significant gaps in our understanding of the impacts of moral distress. This includes gaps in knowledge in mental health about the situations that contribute to the experience, such as involuntary treatment, restraint and coercion, and how moral distress influences patient care (Austin et al., 2008; Deady & McCarthy, 2010; Musto & Schreiber, 2012). Also unknown is the impact of moral distress on patient safety (Austin et al., 2008; Musto & Schreiber, 2012), and the interaction between moral distress, avoidance, compassion fatigue, empathy, vicarious trauma, and burnout of health care providers (Moffic, 2014; Robinson et al., 2003; Severinsson & Hummelvoll, 2001).                                             13 Namely: HEC Forum, Journal of Bioethical Inquiry, and Nursing Ethics 61  Summary of Conceptual Gaps Having reviewed the literature regarding moral agents in this section, I have elaborated on the gaps in our conceptualization of moral distress. I began with the first research on moral distress by Wilkinson, as I believe this study foreshadowed the difficulties subsequent researchers would have, and continue to have, with the concept of moral distress. The gaps in our understanding include:  Ambiguity with regard to Jameton’s original definition, which is related to the consequence of rooting the definition in moral philosophy  Our incomplete understanding of moving moral reasoning to moral action  Lack of insight regarding the role of action in ameliorating the experience  Our difficulty with teasing out moral distress from related concepts such as burnout and compassion fatigue  Limited understanding of the impact of moral distress on patient care14 In the next section of this chapter, I review some of the interventions that have been trialed in an effort to support HCPs to work through experiences of moral distress. In so doing, I continue setting the stage for the rationale for, as well as the implications of, my own study. How Reciprocity May Shape Structures and Agents In this section of the chapter I present my perspective on how I view reciprocity between structure and agents (see Appendix B). The diagram in                                             14 See also Musto and Rodney (2016), Rodney, Buckley, et al. (2013); Rodney, Kadyschuk, et al. (2013) 62  Appendix B is a representation of my thinking about what the reciprocity between structure and agent might look like and a depiction of the potential for iterative change in both. I also assume that HCPs and organizational structures are open systems that have the capacity to adapt and change. As I explore neuroplasticity, I speculate that it is potentially the process that makes change possible as a result of the interplay between structures and agents. Below, I briefly outline the literature from embodiment, neuroscience, and attachment that has informed my thinking about the mutual relationship that exists between health care structures and HCPs. Embodiment. In order to construct an embodied understanding of the interaction between structure and agency, I drew on research from neuroscience that calls for an integrated perspective on human behaviour grounded in evolutionary biology and neurobiology (Damasio, 2010; Moll et al., 2003). An evolutionary perspective is based on understanding the brain as consisting of three parts: the primitive brain that evolved first; the mid-brain or limbic region that plays a role in mediating emotion, motivation, attachment, and memory; and the neocortex, the last part of the brain to fully develop and also the portion that is involved with complex information processes such as perception, thinking and reasoning (Damasio, 1994, 1999; Siegel, 2012). Research by neuroscientist Joseph LeDoux on the experience of fear shows how rapidly the lower structures in the brain respond to a threat and initiate a bodily response to the perceived threat before this information is sent to the neocortex (LeDoux, 2003; LeDoux, 1993). 63  I argued in Chapter One that, at its root, moral distress is a boundary violation, and therefore may be perceived by the body as a threat to survival (Musto et al., 2015). What this means in the context of moral distress as an embodied experience is that when moral boundary violations are perceived as a threat to survival, the fight or flight systems are activated before cognition kicks in (Shay, 2012). Taking this approach to examining moral distress, I am moving away from a merely cognitive understanding of what occurs when our values are violated and toward integrating the whole body response that has been described by participants in research, including this dissertation. In doing so, I hope to further an understanding of moral distress that appreciates moral agents as embodied beings; beings who use their body, brain, and mind15 to determine and carry out moral actions. Thus, I view moral agency as an embodied process whereby individuals are in constant relationship with their environment, making decisions about moral action based on what is possible given the circumstances specific to that moment in time. I outline how I understand the dynamic connection between embodied agents and structures in the following paragraphs.                                             15 For my purposes, in this dissertation I use Siegel’s (2012) definition of the “mind,” which is, “A core aspect of the mind is an embodied and relational process that regulated the flow of energy and information” (p.2). Siegel uses this description as a starting point to discuss the connection between the mind and the brain. Siegel points out that “energy and information flow is what is shared among people within a culture, and this flow is what is measured within a brain scanner” (p.3). This definition of mind can account for my understanding of how we take in information in an embodied way and how that information is shaped by a relational context that is socially, politically, culturally, and historically situated. 64  Embodiment and integration. As our knowledge of the body and bodily systems has grown, we have come to recognize how intimately connected our body is to the environment; so connected, in fact, that we often don’t notice that connection until, for some reason such as a bodily crisis, the connection is interrupted (Schenck, 1986). An example of an interrupted connection, or disembodiment, from mental health care is the experience of dissociation whereby an individual becomes disconnected from his or her bodily experience (Ray, 2006). Dissociation occurs in times of extreme stress or in the aftermath of trauma (e.g. car accident, threatened physical attack etc.) (American Psychiatric Association, 2013). Schenck (1986) points out that the body is in constant communion with the world, and as such, it is the way in which we come to know the world. The same idea is carried through in the literature on structure and agency in the concept of embodied structures. Embodied structures refer to the habits and skills inscribed on the human body by institutional and relational structures that allow these structures to be reproduced or transformed (Elder‐ Vass, 2008). From this standpoint, much of what is inscribed upon our bodies resides in our unconsciousness, outside of our awareness, yet directs our behaviour, and underpins our values and perceptions. For example, in mental health, transference is the act of transferring experiences from one interpersonal relationship to another (Jones, 2004). Although this is an unconscious process and occurs outside our awareness, the result is that a past relationship influences a person’s behaviour in a present relationship (Jones, 2004). The 65  implication for moral distress is that past experiences with ethical challenges will likely influence a HCP’s subsequent responses to ethical challenges. In attempting to gain a greater depth of understanding of the experience, we must first recognize that it begins as a felt (sensory) experience in the body. Within the idea of embodiment, there sits the notion of integration, or a lack of separation between experiencing, thinking, and doing. Historically, the idea of integration does not fit easily with researchers who hold the perspective of scientific dualism that seeks to separate the objective from the subjective, and the emotional from the rational, in order to discover scientific truth (Benner, 2000; Lawler, 1997). However, findings from researchers in neurobiology are beginning to point to the need to understand human behaviour and human decision-making from the perspective of integration between the mind, body, and brain, as well as influences from our environment (Damasio, 1994; Schore, October 2005; Siegel, 2010, 2012). This perspective of integration, coupled with recognition of reciprocity between structure and the agent, has significance for our understanding of moral distress and moral agency. Recognizing moral distress as an integrated and embodied experience opens up new spaces to develop interventions. One example of developing interventions within a framework of understanding moral distress as an integrated experience comes from Rushton, Kaszniak, and Halifax (2013b). These researchers have developed a framework for understanding moral distress that incorporates emotional attunement, cognitive attunement, and personal experience, with responses that result from perceived violations of professional 66  ethical responsibility. The framework highlights potential areas for intervention that may help ameliorate the experience of moral distress (Rushton, Kaszniak, & Halifax, 2013a). In developing a framework that can accommodate an embodied response to moral distress, Rushton, Kaszniak and Halifax reached across the disciplines of nursing ethics, social psychology, and neuroscience. Neuroplasticity. Researchers in neuroscience have added to our knowledge base in two areas that are pertinent to my study of the reciprocity between agents and structures: broadening our knowledge of structural and functional brain growth, and providing insight into how moral thinking may take place in the brain. Neuroplasticity refers to an adaptive response by which neurons seek out and form new pathways (Doige, 2007; Edelman, 1993). It is dependent upon a confluence between elements within an individual, such as genetics and environmental factors. For example, research in neuroscience and mental health supports the contention that mental illness is a result of a combination of environmental factors, genetics, and neuroplastic changes (Kays, Hurley, & Taber, 2012; Pittenger & Duman, 2008). Structural changes will be seen in the brain of an individual who practices a skill (e.g. mediation, music, or sports) on a daily basis (Doige, 2007). Pruning, or neural depletion, is also detected in the brain when neural pathways are no longer used or not used as regularly (Underwood, 2006). Pruning is also observed in people who experience chronic stress (Davidson & McEwen, 2012). Another important feature of neuroplasticity is that the brain is adaptive, depending on the environment. For example, although neurons appear to shrivel when a person experiences 67  ongoing stress, the neuropathways do not actually die, and the changes appear to be reversible (Davidson & McEwen, 2012). This potentially means that a health care environment has the capacity to enhance or inhibit neural growth and that the neural growth is amenable to change depending on the factors influencing that environment (Beumer, 2008; Musto et al., 2015). Morality and neuroscience. Researchers in neuroscience have also moved the debates in moral psychology beyond the polarized gender debates regarding Kohlberg and Gilligan by demonstrating that moral reasoning is complex and draws on a variety of areas in the brain (Damasio, 1994; Lapsley & Carlo, 2014; Moll & de Oliveira-Souza, 2007; Moll et al., 2003). Morals are found to be deeply embedded in the brain and draw on the same circuitry as emotions (Decety et al., 2011; Moll et al., 2003), indicating that values are emotionally held and that it is not possible to separate thinking about values from an emotional response. Indeed, researchers examining individuals with particular brain lesions found that effective moral reasoning may require the incorporation of prosocial moral emotions (Damasio, 1994; Moll & de Oliveira-Souza, 2007). These findings also indicate that moral judgment begins outside of our conscious awareness and direct moral action without intentional reflection. This has led researchers to debate the connection between moral reasoning and moral action16 (Greene, 2003; Greene & Haidt, 2002; Kihlstrom, 2013). These findings have implications for our understanding of moral agency and moral distress. In particular, these                                             16 For an overview of the debate regarding moral action please consult John Templeton Foundation, Does moral action depend on reasoning (2010), at http://www.templeton.org/reason/ 68  findings may point to the importance of interventions that focus on discussion, such as the one described by Wocial et al. (2017), to create an open space for bringing moral intuitions and judgments into conscious awareness so HCPs can take thoughtful and intentional moral actions. I noted at the beginning of this section that emotions and moral appear to be intertwined. As such, central to being able to discuss ethical situations is the ability to regulate our emotional states, or to self-regulate. The capacity for self-regulation begins in infancy in the parent-child relationship, however, continues to be shaped by interpersonal relationships and contexts across throughout life (Narvaez, 2014; Schore, 2005; Siegel, 2012) Attachment. Siegel (2012) defines attachment as “an inborn system in the brain that evolves in ways that influence and organize motivational, emotional, and memory processes with respect to significant caregiving figures” (p. 91). Although attachment forms in infancy around primary care givers, these early relationships can have a significant effect on subsequent relationships and an individual’s capacity to self-regulate across the life span (Schore, 2002, 2005; Siegel, 2012). Researchers in attachment have linked the quality of early attachment relationships to subsequent vulnerability to mental health problems (Schore, 2005; Siegel, 2012). As well, secure attachment is perceived to be protective against the physiological and emotional consequences of stress (Gunnar, 1998; Maté, 2003). Conversely, brain scans comparing brain structures of securely attached individuals against individuals raised under traumatic or neglectful circumstances reveal marked differences in brain structure and volume 69  (Perry, 2004). Environmental issues, such as neglect or trauma, disrupt or impair structural development in the brain (Gunnar, 1998; Perry, 2004, 2009). Thus, early (external17) attachment experiences shape the (internal) brain structures of an individual, setting a template for the person’s capacity to manage adversity in later life.  As I noted above, although attachment begins in infancy, it continues across the life span, albeit in a different form, and in times of stress, many adults engage in behaviours that reflect a need for comfort, support, or advice, and seek out someone viewed as an attachment figure (Siegel, 2012). For adults, this may include close friends, family members, or mentors. For example, in my earlier research with mental health nurses working with adolescents, after experiencing a distressing situation, several nurses described seeking out colleagues they viewed as mentors for support or advice on how to manage the situation the next time it occurred (Musto & Schreiber, 2012). The above material has informed my study in several ways. First, the process of forming attachment relationships and results of these attachment relationships are examples of how external structures, relationships, and processes, have a clear and direct influence on the internal structures of an individual. The processes that are shaped in the person through the attachment relationship across their lifespan (for example the regulation of internal states,                                             17 In Chapter Three, I present a case for extending the definition of structure to encompass both—the internal biological, physiological, psychological, and emotional structures and processes of the person, as well as structures (material and non-material) in the external environment. 70  social engagement, and the capacity for self-reflection) will also have an impact on the environments they inhabit. In this research, the environment is the complex and stressful health care setting in which they work. As well, the fact that HCPs have a propensity to seek out colleagues and mentors when faced with a morally distressing situation, provides a potential avenue for intervention. Review of Interventions in Moral Distress Some individual strategies identified to ameliorate moral distress include education in ethics and moving ethics to action, improving communication, seeking support from ethics committees and/or chaplaincy, developing critical self-reflective skills, and building personal resiliency (Burston & Tuckett, 2013; Rodney, Kadyschuk, et al., 2013). Other strategies directed at a more collaborative approach to alleviating moral distress include, but are not limited to, fostering inter-professional dialogue to facilitate a greater understanding of the perspectives of other disciplines, as well as interdisciplinary ethics education and ethics rounds (Burston & Tuckett, 2013; Rodney, Buckley, et al., 2013).  Notwithstanding the abundance of research in moral distress, in particular over the past decade, I have be able to locate only four empirical studies actually focused on measuring the effectiveness of interventions (Beumer, 2008; Kalvemark Sporrong et al., 2007; Rogers, Babgi, & Gomez, 2008; Wocial et al., 2017). This may be a reflection of the current state of the concept of moral distress, along with difficulties in devising effective ways of measuring such a complex phenomenon. Three of the studies were education based, while one 71  study focused on fostering open discussion in ethically challenging situations (Wocial et al., 2017). In the studies where researchers focused on educational interventions, only two studies focused on developing ethical competency and the third provided education about moral distress and strategies for coping. One study by Rogers et al. (2008) offered monthly, one-hour educational sessions over a six-month period. Topics for the educational sessions consisted of: pain management, symptom management, ethical/legal issues, communication/culture, spiritual/anxiety issues at end-of-life, and prevention of compassion fatigue. The topics resulted as follow-up on problematic clinical, ethical. and legal issues surrounding neonatal care (Rogers et al., 2008). This intervention was developed in response to moral distress experienced by HCPs on a neonatal intensive care unit (NICU), with the main goal of improving neonatal and pediatric end-of-life care, and potentially resolving some of the morally distressing issues. Pre and post-measures demonstrated that the participants found the educational intervention helpful overall in increasing their comfort levels in working with neonatal end-of-life issues.  Interestingly, although Rogers et al. (2008) recommend educational intervention for NICU health care staff, they state that “The most important piece to take into consideration is providing the NICU staff with all the support they need” (p. 64). Thus, they further recommend ongoing support, debriefing with outside experts, multidisciplinary team meetings, and sessions to discuss lessons learned following the death of an infant. These recommendations make it difficult to determine if the education provided was solely responsible for the 72  increased level of comfort expressed by the participants, or if the opportunity to spend time discussing the issues confronting the nurses related to end-of-life care contributed to the overall benefit of the intervention. Kalvemark Sporrong et al. (2007) offered a multidisciplinary intervention directed toward developing ethical competence. Participants were drawn from two areas: pharmacies and clinical settings. The intervention consisted of three ethics lectures and three ethics rounds. The ethics lectures included information regarding ethical theory as a tool for decision-making, theories of human dignity, and topics pertaining to medical ethics such as prioritization in health care practice (Kalvemark Sporrong et al., 2007). The ethics rounds were multidisciplinary and incorporated ethical discussions of situations from clinical practice. The level of moral distress was measured pre and post intervention; however, the participants demonstrated no statistical benefit from the intervention. Having said this, participants did express appreciation for the opportunity to discuss morally laden problems they confronted in everyday clinical life. The authors offered some potential explanations for this finding, including that the intervention was not sufficient to impact the outcome variables and the intervention actually increased awareness and understanding of the underlying moral issues. A third reason offered by the authors was that the lower attendance rate of the clinical staff was due to lack of time and work tasks that could not be handed over to anyone else (Kalvemark Sporrong et al., 2007). This sampling of some of the potential explanations for a lack of statistical change may also be an indication that interventions need to take into account the needs 73  of the audience, and ensure that they are directed toward these needs (Hamric, 2012).  In his study, Beumer (2008) offered a workshop that provided education targeted specifically to moral distress. Nurses had the opportunity to identify situations that created distress and discuss the impact these situations had on them. They were provided with information about moral distress, along with strategies to help manage it. Each participant was encouraged to develop a plan to reduce stress and improve his or her individual well-being. The nurse manager joined the group to discuss unit-specific strategies to minimize or cope with moral distress (Beumer, 2008). Pre and post measurements were taken, along with measurement from a control group that had not been involved with the intervention. Beumer (2008) found that participants experienced an overall decrease in their experience of moral distress, and importantly, an improved involvement with the patient and an improvement in the overall work environment. While it would be simple to declare the educational component in Beumer (2008) study effective, it would also be premature. Beumer’s intervention captures the complexity of understanding moral distress as an embodied experience that is in relation to the health care environment. Although Beumer’s intervention study was educationally based, it also included participation from the nurse manager and an opportunity to problem-solve unit issues collaboratively. Further, there was an opportunity for individual voices of bedside nurses to be heard by management, and as such, directly confronted several elements that 74  contribute to moral distress. Conversely, the participation of the nurse manager may have also confounded Beumer’s findings; for example, did the staff feel comfortable bringing up critical ethical concerns with the manager in the room? Surprisingly, given the positive impact of this intervention on patient care and the work environment, this intervention strategy was not taken up within the organization. One of the reasons given was that of the commitment required to schedule staff and ensure staff attendance outside the nurses’ work commitments (Beumer, 2008).   Wocial et al. (2017) published findings from an interdisciplinary discussion-based intervention directed at fostering open communication between team members in ethically challenging situations as a means of decreasing moral distress. The intervention was provided in the form of interdisciplinary team ethics rounds, and was focused, at a clinical level, on patients with an extended length of stay in the Pediatric Intensive Care Unit (PICU). Researchers identified greater ethical challenges with this patient population, due to increased chances for inconsistencies in management strategies, and the possibility for communication difficulties, due to delays in talking about sensitive ethical issues. The intervention took place over a period of 12 months, and involved weekly interdisciplinary ethical rounds facilitated by an ethicist; all professionals involved in the care of the patient were expected to attend these discussions. The intervention was measured using two different instruments. The Moral Distress Scale-Revised (MDS-R) was used to measure moral distress pre and post 75  intervention. Participants also used the Moral Distress Thermometer (MDT) on a monthly basis to rate their level of acute moral distress. Researchers reported mixed results, because participants uniformly noted that participation in the intervention improved communication between team members, and they indicated an improved ability to communicate with patients and family members. However, the researchers were not able to report a statistically significant decrease in moral distress scores. This finding foregrounds the importance of gaining conceptual clarity on the definition of moral distress in order to develop interventions effectively to address the experience of moral distress. It may be that elimination of moral distress in ethically challenging situations is not possible. Instead, perhaps researchers ought to develop interventions aimed at supporting HCPs and teams navigating the experience without carrying the lasting negative effects of unresolved moral distress. It is also worth noting that, in describing the setting for this study, the researchers describe the hospital context as having a robust training program for medical staff, while leadership at the program level is described as being supportive of medical and nursing staff and as having established a “strong trusting relationship between unit staff and the ethicist” (Wocial et al., 2017, p.78). These descriptors highlight how context may shape the research results and the individual capacity for moral agency. Summary of interventions. The four intervention studies above, while important, also demonstrate some of the ambiguity that exists in our 76  understanding of moral distress. They further indicate the possibility that effective interventions may need to be tailored to the organizational and clinical setting. Only the study by Kalvemark Sporrong et al. (2007) included a combination of non-nursing HCPs, and clinical departments. Consequently, the intervention studies discussed above provide little insight into interventions that may be suitable across health care professions or settings, and offer no direction for promoting a collaborative approach to working through moral distress. In order to move forward in developing effective interventions that support HCPs in fulfilling their moral obligations to their patients, we need to move away from the linear definition of moral distress discussed in Chapter One. Instead, we need to explore moral distress as an embodied experience that is a result of the interaction between and among the broader societal structures that shape health care delivery, organizational structures, and complex structures within the moral agent. A view of moral distress as a phenomenon that results from the interplay between structures and moral agents may allow the development of interventions that can attend to the specific context of the HCP as well as broader contextual issues. For example, Beumer’s intervention which is an explicitly educational one focused on providing information and the development of self-care for nurses, actually positively impacted both patient care and the work environment. Working with the reciprocity that exists between structures and agents provides the potential to harness that reciprocity intentionally to create change in both the HCPs and the health care organization. In the next section, I point to the 77  literature that supports a view of moral distress as an embodied experience shaped by, and through, interaction with the health care environment.  Organizations. Much of the information provided above centers on internal structures and processes of the individual. However, woven through the discussion is recognition that an individual’s internal environment is shaped, and continues to be shaped, by external contexts. In this final section, I turn to the work of Shay (1994, 2010, 2012) to explore the influences and consequences of organizations. I introduced the theme of reciprocal responsibility between organizations and HCPs in discussing the location of moral distress. The call for mutual responsibility and accountability in the provision of health care services clearly emerges from the research of Austin et al. (2003; 2005; 2008) as an appeal from all the HCPs involved in her studies. It also echoes research from outside the field of health care. Jonathan Shay is a military psychiatrist working with American soldiers returning from combat with a diagnosis of Post-Traumatic Stress Disorder (PTSD) (Shay, 1994). He found that the diagnosis of PTSD was inadequate to account for the destruction of moral character the soldiers experienced. The concept of moral injury18 arises from Shay’s work and provides a coherent example of challenges in the symbiotic relationship that exists between structures and agents. The notion of moral injury is defined as a betrayal of what                                             18 I recommend Shay’s work on moral injury and direct the reader to his writing for a deeper understanding of his analyses (Shay, 1994, 2010, 2012). As well, Litz et al. (2009) have researched and written about the concept of moral injury. 78  is right by a legitimate authority in a high-stakes situation (Shay, 2012). Shay’s support for the concept of moral injury is drawn from the fact that the military is a socially constructed organization created by society and defined by shared expectations and values. According to Shay (1994), the relationship between the military and their soldiers is based on the assumptions of shared risk of death, and a fiduciary assumption that the military will provide soldiers with the necessary information, equipment, supplies, and support to carry out their mission.  Moral injury in that situation resulted from a betrayal of both assumptions. I see several parallels to health care when drawing on Shay’s work: health care organizations are social constructions involving shared values and expectations, and the drive for cost constraints and efficiency (along with HCPs being held accountable to a Code of Ethics and Standards of Practice that are not shared by health care organizations) have led to a sense of betrayal in the context of moral distress (Musto et al., 2015). I revisit these parallels in the Chapters Six and Seven of this dissertation and address them in terms of the GT I create on the basis of my research. Another parallel I make with Shay’s work reflects the impact that organizational behaviour can have on those in their employ. I am interested in the connection between organizational culture, neuroplasticity, and embodiment. The soldiers at the center of Shay’s work experienced a destruction of character to the extent that they were unable to engage in the world as they had before they went to war (Shay, 1994). Given the above discussion on neuroplasticity, 79  the implication is that chronic stress and fear led to structural changes in the soldiers’ brains. Shay’s work suggests that the actions of an organization can permanently alter the character of an employee. My purpose in drawing on Shay’s work is to reinforce the idea of reciprocal influence and mutual responsibility between structures and agents, in particular, structures that are socially constructed and then reflect the values and expectations of society (Musto & Rodney, 2018; Musto et al., 2015). While I am not suggesting that HCPs experience the same depth of trauma as soldiers in battle, I am suggesting that the sense of betrayal experienced by HCPs may be a significant element of moral distress (Musto et al., 2015; Rodney, Kadyschuk, et al., 2013). It is my premise in this dissertation that we need to gain a better understanding of the interaction that occurs at the intersection of structures and agents in order to develop interventions that support ethical choices; interventions that support wholeness in HCPs and fulfill the fiduciary obligations of health care organizations. Chapter Summary   In this chapter I provided an overview of the literature on moral distress in order to illuminate the gaps in our knowledge that need to be clarified if researchers are to be able to plan intentional interventions that support HCPs in fulfilling their moral obligations to patients. Lack of conceptual clarity in moral distress includes: 80   gaps in our understanding of how moral agents move moral decisions to moral action;  gaps in our understanding of the role of action in ameliorating moral distress; gaps in our understanding of the concept of what actually constrains action;  an inability to tease out closely related concepts such as burnout and compassion fatigue from moral distress;  a nascent understanding of the impact of moral distress on patient care, including the consequences of avoidance in relation to FTR;  limited research on moral distress in mental health care; and  no research on the impact of moral distress on patient care in mental health. As I discussed at the beginning of this chapter, the issues of direct care delivery at a local level are a reflection of broader societal issues that underpin health care delivery. These issues include a global shortage of skilled HCPs, ideologies of cost constraint and efficiency, and neoliberal beliefs. In Canada, with the recent lapse of the Health Accord and a shift to a further decrease in the sharing of health care cost, local health authorities are going to be further stretched to constrain health care spending through increased efficiency. These efficiencies will increasingly challenge HCPs to provide care for their patients that align with their moral obligations. The Mid Staffordshire Trust Inquiry (2013a) stands as a stark example of what can happen when HCPs are unable to enact their moral agency in an 81  environment driven by cost constraint and efficiency. It is worth noting that the patients who suffered most in the Mid Staffordshire Trust were the elderly, one of the most vulnerable patient populations. The acute health care system and community mental health system responsible for providing care for patients who struggle with mental health problems, also a vulnerable population, is chronically underfunded (Mental Health Commission of Canada, 2012). While there exists some research on moral distress with mental health professionals, no research exists that examines the impact of moral distress on the quality of patient care. This being the case, the research undertaken in this study is necessary in order to lay the foundation for effective interventions in moral distress. 82  Chapter Three Theoretical Framing  As is the case with most research projects, the proposed process for conducting research on moral distress in mental health care is shaped by the research question and how that question can best be answered. My research question centers on examining how HCPs enact their moral agency in the current health care climate. It was evident in Chapters One and Two of this dissertation that the experience of moral distress is not a linear process, but is influenced by various internal and external factors, leading to outcomes that may take different forms. A further premise is that the process, or experience, may be interrupted, and changed as new experiences occur.  Phrased another way, I assert that agents and structures exist in a reciprocal relationship and are changed as they interact with each other, and that they are changed according to the meaning the agent attributes to the interaction. In the context of moral distress, this means that the outcome of the experience cannot be predicted; rather, the outcome is dependent upon a confluence of circumstances and individual attributes. In speculating about the nature of structures and agents and the reciprocal relationship that exists between them, I assume that neither can be completely understood directly through the collection of only sensory research data. Instead, I believe that understanding structures and agents is a complex and layered process requiring the use of sensory data, as well as reasoned theorizing about the processes that 83  underpin this reciprocity, based on research from other disciplines such as neuroscience. In this chapter I make explicit some of the assumptions underlying my research question, and lay out the theoretical framework that underpins my ontological, epistemological, and methodological research approaches. I review the ontological positions of positivism, post-positivism, and constructionism. Following this, I review my theoretical framing in the context of critical and relational inquiry, and critical realism. Finally, I address the implications of the theoretical framing for this research and link that framing to my selection of GT as a methodology. Grounded Theory Methodology (GTM), with roots in symbolic interactionism and pragmatism, will take into account the assumptions I identified above. However, before moving on to my ontological position, I further explore the foundational terms, such as structure and agency, that underpin my decisions regarding epistemological and methodological approaches. Exploration of Foundational Terms Structure In much of the literature I have discussed in Chapters One and Two, the definition of structure was often just implied, leaving the reader to supply an explanation depending on the context. In reviewing the literature across nursing ethics, attachment theory, moral psychology, sociology, and neuroscience in relation to moral distress, I realized that both external structures in the health 84  care environment, such as resources, and structures internal to the individual contributed to constraining action, but that the constituents of internal and external structures may differ. In other words, some structures were material or observable (e.g., written policy), and other structures were non-material and not directly observable (e.g., internal psychological processes), yet both forms of structure influenced the agent’s ability to act. Inadequate policy, or policy that conflicts with professional or personal values, may form material and observable structures that constrain action and result in moral distress. Thus, an observable example may be hospital policy that results in an inadequate ratio of Registered Nurses (RNs) to acutely ill patients (Musto et al., 2015; Musto & Schreiber, 2012; Storch et al., 2002). Hierarchical relationships imbued with power within health care teams are examples of structures that are not observable yet also constrain the actions of others (Deady, 2012; Jameton, 1984). Both of these examples reflect external constraints that inhibit action. However, understanding observable and unobservable structures is necessary but not sufficient; such understanding does not illuminate the relationship of agency, or how agency could effect change in these circumstances. To adequately define structures, then, I begin with some of the literature in sociology. Specifically, I draw on both the social sciences and the natural sciences. In what follows, I explain that I view structures as being both material and non-material, as having emergent properties, and having the capacity to have influence. In using this definitional framing, I understand structures to 85  extend from the external environment in which the agent lives and works, to the deeply internal environment of the agent.   Structures as material and non-material. Theorists from sociology19 have grappled with a definition of structures and note ongoing ambiguity with the existing definition (Elder‐ Vass, 2008; Sewell, 1992). Sewell (1992), a political scientist and historian, identified what he viewed as, “the three cardinal weaknesses” (p. 3) of structure in the social sciences. He sees the weaknesses as failures: (1) to recognize the agency of social actors; (2) to build the possibility of change into the concept of structure; and (3) to overcome the divide between semiotic and materialist views of structure (p.3). Accounting for agency and the possibility of change are both relevant to my discussion, and so I will draw on Sewell’s perspective on the duality of structures to support my understanding of structure in the context of my dissertation.  In discussing the duality of structures, Sewell (1992) is drawing on Giddens’ structuration theory, which posits structure as both a medium and an outcome. This means that, “structures shape people’s practices, but it is also people’s practices that constitute (and reproduce) structures” (Sewell, 1992, p.                                             19 Because my purpose is to discuss structure(s) in relation to moral distress, I will provide an overview of the discussion on the definition of structures mainly as it pertains to moral distress. From a critical realist position, Archer (1998) and Edler-Vass (2008) theorize about the relationship between structure and agency in the context of change and point to the emergent properties of structures. Please see Sewell, Elder-Vass or Archer for a comprehensive discussion on structure in the social science literature. 86  4). Inherent in this definition is the idea of reciprocity between structures and agents. Sewell interrogates Giddens’ definition of structure and finds it somewhat ambiguous. In order to maintain the central theme of the duality of structures, Sewell conducts a careful exegesis of Giddens’ definition and draws on Bourdieu’s idea of habitus in order to re-conceptualize a theory of structure that will account for the weakness identified above. In his definition of structures, Sewell (1992) maintains the central theme of the duality of structures and states that structure “should be defined as composed simultaneously of schemas, which are virtual, and of resources,20 which are actual” (p.13). For my purposes, I retain Sewell’s understanding of structures as having a dual character, being both virtual (non-material) and actual (material), and agree that structures in both forms can be understood to exert an influence on agents.  However, in extending the definition of structures to include the internal environment of the agent as well as the external environment, I move away from a strictly sociological understanding of structures to a general definition of structures incorporating biological, physiological, and social elements, and processes. I elaborate on these concepts when I discuss structures as internal and external.                                             20 It is not my intention to critique Sewell’s theory, however, I believe that one of the weaknesses in the theory is that he defines resources solely as material. Psychological resources, for example resiliency, may also be seen as a resource. I view resources as both material and non-material. Support for this view of psychological resources can be found in the work of Allan Schore (2003) and Dan Siegel (2012). 87   Structures as emergent. I also view structures as having emergent properties. Elder‐ Vass (2008) draws on critical realism to explain structures as social wholes that possess emergent properties. Key to this conception of emergence is the understanding that emergent structures are not reducible to their parts (Cruickshank, 2012; Elder‐ Vass, 2008). A common example used to describe emergence is found in the natural sciences: water is considered an emergent property of hydrogen and oxygen but is not reducible to either part (Cruickshank, 2012). Viewing structures as emergent is one way to explain how change may occur in the relationship between structures and agents. Although Sewell does not use the terminology I have used when theorizing change, he identifies five key axioms (or emergent properties) that come together in contingent ways to generate a transformation of structures (Sewell, 1992). Agency is a central element that influences the contingent way in which these emergent properties come together to influence structures. He views agency as “the actor’s capacity to reinterpret and mobilize an array of resources in terms of cultural schemas other than those that initially constituted the array” (p.19). It is important to note that the concept of taking action based on interpretation of the situation also echoes the three premises of symbolic interactionism (SI) articulated by Blumer (1969), which are that (a) people act toward things based on the meaning these things have for them, (b) the meaning of things is derived out of social interaction, and (c) meaning is handled in, or modified through, an interpretive process. Inherent in Blumer’s three premises and Sewell’s definition of agency, is the idea of a knowledgeable actor making 88  intentional choices. Also evident is appreciation of the contingent ways in which structures and agents come together and shape each other.  The interaction between agents and structures necessarily becomes the site of research in order to tease out the contingent way in which agents and structures influence each other. Consequently, for my research, a methodology that focuses on understanding meaning and action, and considers the broader sociological context that shapes meaning and action was needed. As I have indicated earlier, GTM is designed to examine process, interaction, and the meanings participants give to the situation. Depending on the orientation and purpose of the researcher, a critical perspective in GT can be brought to the study examining the structural processes and conditions that shape the context (MacDonald, 2001). For my research, the consequences of viewing structures as emergent meant recognizing that the development of structures internal to the agent are shaped by, or contingent on, emergent properties such as genetics, temperament, family upbringing, and the external environment. Structures as internal and external. To define structures, I began with sociology, and a sociological explanation of social structures external to the agent. Specific to my research, political ideologies that shape health care culture, policies, and unit culture are some of the external but often unobservable structures that shape the health care environment of participants. Ideologies may include neoliberalism, or the dominance of a market model, in which efficiency, and cost effectiveness underpin policy in the delivery of health services (Austin, 2011; Pauly, 2013; Rodney, Harrigan, et al., 2013; Rodney & Varcoe, 2012). The 89  Lean Model has been adopted in health care service delivery from the business sector and some health care researchers question the appropriateness of applying a business model to health care delivery (Austin; Rodney & Varcoe). Other external structures that shape health care delivery include, but are not limited to, resource allocation, power and gender inequities, and organizational policy (Rodney, Harrigan, et al.; Sherwin et al., 1998). As I have argued above, for my research, I wanted to extend my study of structure from external to also include structures internal to the agent. The internal structures I am referring to are the biological, physiological, and psychological objects and processes such as cells, tissue, organs, hormones, biological systems, emotions, cognition, ideas or concepts, and so forth that influence the internal state of the person. When the definition of structures is limited to the external environment, what is actually occurring within the individual is overlooked. In extending our appreciation of structures to include the internal environment of the individual, moral distress as an embodied experience can be intentionally explored. I divide internal and external structures at the boundary of the body. However, I acknowledge that this may be a somewhat artificial boundary, as research from the human sciences and medicine demonstrates that the external environment can have a significant effect on the internal structures of the body (Mate, 2011). An example of the interplay between external and internal structures is seen when exposure to environmental stress (for example, conflictual relationships), can increase the body’s vulnerability to disease (Mate, 90  2011; Sapolsky, 2004). The impact of stress on the body is a negative example of how external structures can have a negative influence on internal structures; however, the opposite is also true. Research on attachment demonstrates that attuned caregivers support neural growth in areas of the brain responsible for emotional regulation (Schore, October 2005; Siegel, 2012). My purpose in extending the definition of structure to include internal as well as external components is to highlight the embodied nature of agency. In the context of health care delivery, constraints on the enactment of moral agency are complex and likely to be a combination of internal and external factors. An example of external and internal structures constraining action may be seen in an interaction between a HCP and his or her manager. If a HCP is unable to provide adequate care due to lack of resources, (e.g., supplies, space or time), and believes the way to address this situation is to speak to his or her manager, he or she may be constrained from action due to anxiety or fear of conflict. Alternatively, he or she may criticize others who are trying to take positive action by listening to patient and family concerns (Rodney, Kadyschuk, et al., 2013). Significantly, both forms of structure also shape each other and are central to the concepts of taking action and creating change. Of importance for my discussion is the recognition that structures—material and non-material, as well as internal or external—have a direct bearing on the role of action in the experience of moral distress. In other words, the experience is embodied as well as emotional. 91  Moral Agency Moral agency has been described as an individual’s capacity to direct his or her actions to bring about a moral end (Storch, 2013). Central to the experience of moral distress is the concept of constrained agency (Rodney, Kadyschuk, et al., 2013; Rodney & Varcoe, 2012). Jameton’s conception of the experience of moral distress is that it manifests as a consequence of not taking action (Jameton, 1984, 1993; 2013). As I noted in Chapter Two, gaining insight into the role of action in the experience of moral distress may help in the development of interventions. Our understanding of agency in bioethics is evolving in response to the feminist critique of the concept of action (Peter, 2011; Rodney, Kadyschuk, et al., 2013; Sherwin, 1998). Historically, in the bioethical literature, agents have been portrayed as independent and self-determining individuals with little attention paid to how context influenced their decisions (Rodney, Kadyschuk, et al., 2013; Sherwin, 1998). Feminist critique has called attention to how the traditional views of agency obscure the sociopolitical context in which decisions are made and, instead, call for a relational approach to health care ethics (Sherwin, 1998). The consequence of this critique for my study was that I needed to attend to how the context of the health care environment shapes meaning and action for the participant (agent). Earlier in this chapter, I presented Sewell’s definition of agency, which was built on a person’s capacity to make new meaning out of a situation and mobilize resources (Sewell, 1992). Sewell’s definition also suggests that taking action is a component of agency. However, agency cannot be discussed separately from 92  autonomy. Indeed, Sherwin (1998) identifies the interdependence of the two concepts as she argues for a relational approach to autonomy. Sherwin defines agency as “the making of a choice,” and autonomy as, “self-governance” (p. 33). The concept of autonomy is used to discuss both a developmental process in early childhood, as well as a bioethical principle.  Given my understanding of agents as embodied, the developmental process of autonomy is clearly linked to self-governance in adulthood. Theorists have pointed to autonomy as a biological and physiological process that is shaped by experience with the external environment, particularly interpersonal relationships (Erikson, 1997; Narvaez, 2014; Ryan, Kuhl, & Deci, 1997; Schore, 2005). Consequences of autonomy as a developmental process relate to a person’s capacity for self-regulation (self-governance) (Ryan et al., 1997). Self-regulation, or the ability to manage emotional states (Siegel, 2012), is foundational to reasoning, making choices, and taking intentional action. This understanding of the relationship between autonomy and self-regulation in the context of taking intentional action to alleviate moral distress has implications for the health care environment. As well, awareness of the influence of interpersonal relationships on an individual HCP’s ability to regulate may be a site for interventions. Woven through the above discussion defining structure and agency are the ideas that the actions taken by HCPs in morally distressing situations are shaped by a reciprocal relationship between internal and external structures, and are based on meaning that is contextually and relationally situated. In presenting 93  action from this perspective, I take the position that action is contingent on a variety of elements (Nairn, 2012); therefore, what can be known empirically about the influence of taking action on the experience of moral distress is contingent on both the internal context of the HCP and the health care environment. Keeping this discussion in mind, and building on my earlier discussion in the next section I situate my ontological positioning for this research within critical realism. Ontological Positioning In order to establish congruency between ontological and epistemological approaches, it is necessary to make explicit the beliefs about the nature of reality and how knowledge is developed that guide me in this research. I begin with a brief overview of positivism, post-positivism, and constructionism, and then outline my reasons for taking up a constructionist position. Positivism Although Alversson (2009) and others have argued that a strictly positivistic approach to science is dead in our current era, positivist assumptions in the form of randomized control trials as the gold standard for research remain prevalent in our current health care system (Goldenberg, 2006; Upshur, 2005). A positivist view of reality is based on the assumption that reality and the causal laws underpinning reality are waiting to be discovered, and function in a linear and predictable manner. A positivist approach to health care is based on the assumption that population health, interventions, and changes in health status can be quantified, and that they occur in a linear, cause and effect, fashion. In 94  the context of moral distress, a study conducted from a positivist perspective could measure the frequency and intensity of moral distress but would not be able to tell us about the meaning of the experience. A positivist belief that events occur in a linear fashion is based on a view that a concrete reality exists outside of our thinking (realism), and is ordered and governed by a set of unchanging laws. The corollary of these beliefs is that these laws can be discovered through rigorous application of the scientific method. In keeping with positivism, the central tenets of the scientific method are objectivity, measurability, and verification (Polifroni & Welch, 1999). Critiques of positivism assert that it is mechanistic and reductionist as, in order to determine causation, context must be stripped from the situation (Crotty, 1998; Goldenberg, 2006). Further critiques include the separation of fact from value, and the placement of the researcher in the role of an objective observer who has no impact on the objects under study (Charmaz, 2006; Crotty, 1998; Yeo, 1994). The idea of objectivity incorporates the belief that these unchanging laws are a-contextual and a-historical (Agger, 1998; Crotty, 1998). An accompanying assumption is that rigorous application of the scientific method will eliminate researcher bias that may taint the objectivity of scientific findings. Scientists’ and philosophers’ critiques of these positivist claims have resulted in a movement toward a “softer” form of positivism known as post-positivism. Post-Positivism Post-positivism emerged out of positivism and takes a more tentative stance in its claims to truth and knowledge. Post-positivism maintains the belief 95  in the existence of a single external reality, but concedes that reality cannot be fully apprehended through empirical means (Crotty, 1998). Rather, use of empirical methods will lead to an approximation of reality that we cannot come to know fully because of hidden variables and a lack of absolutes (Lincoln, Lynham, & Guba, 2011). As well, a post-positivist maintains the position of the researcher as a disinterested observer out to discover new knowledge, thereby holding on to the belief of some level of objectivity in research. Philosophers such as Kuhn (1977) have successfully argued the untenability of the positivist position of objectivity and the separation of facts from values by demonstrating that scientists are historically and culturally situated and, as such, are active participants in the construction of knowledge (Agger, 1998; Crotty, 1998). Despite a softening of a positivist stance, post-positivism is still based upon using empirical methods in the discovery of knowledge. This means that results from empirical studies on moral distress remain at a descriptive level, which makes a quantitative approach inadequate for the exploration of complex phenomena such as how HCPs manage morally distressing situations in practice. Constructionism In my exploration of constructionism as an ontological position for this research, I have grappled with the difference between constructionism and constructivism. My exploration revealed that these concepts remain contested, and developing an understanding of them is complicated by the fact that researchers and scholars write about these terms in different ways. For example, in Denzin and Lincoln’s (2011) text entitled The Sage Handbook of Qualitative 96  Research, the idea of constructing knowledge falls primarily under a constructivist heading in which social critique is central. Lincoln, Lynham and Guba (2011), in their constructivist paradigm, hold to the belief that knowledge construction is an intra and interpersonal process, and results in the existence of multiple realities, or multiple truths; thus, no single reality takes precedence. This view of constructivism clearly falls into a subjectivist and relativist paradigm. An individualist approach to the production of knowledge fails to account for the influence of social structures on individual meaning-making and action (Browne, 2001; Clark, Lissel, & Davis, 2008; Cruickshank, 2012). As I planned to examine how moral agents take action in the context of the structures in which they work, I needed to be able to account for the influence of social structures. Another difficulty with constructivism is that a critique of culture, society, and the structures that frame and influence the creation of meaning and knowledge becomes impossible if the only knowledge that counts is created individually (Crotty, 1998). Yet, as I noted earlier, critique of assumptions that underlie our current system of health care delivery, along with the power structures that maintain these assumptions, is imperative if change is to occur. Crotty (1998) takes a different approach to that taken by Denzin and Lincoln (2011), making a distinction between constructionism and constructivism. He describes constructivism as an individualistic understanding of constructionism. Crotty (1998) contends that constructionism is opposed to the belief that knowledge is revealed or that knowledge inherently resides within an object, but instead arises from the belief that all knowledge is constructed and 97  that construction of knowledge occurs through interaction with the object. In describing constructionism, Crotty portrays an active and reciprocal relationship between the object and the individual, as he parallels constructionism with intentionality. When used in this way, intentionality is a “radical interdependence of subject and world” (Crotty, 1998, p. 45). He also points out that individuals are born into a cultural system that already tells us how to engage with the object. From this perspective of knowledge, the idea of understanding the meaning that is attributed to an object, and how that meaning is developed, becomes integral to the research process. Understanding how HCPs construct meaning regarding their moral obligation(s) to their patient may provide insight into how health care policy constrains or supports their fulfillment of these obligations. Consequently, it was important that I chose a research methodology that allowed me to be attentive to the importance of the meanings ascribed to a situation or an object. The origins of grounded theory (GT), the methodology I have chosen for the study, are in symbolic interactionism (SI) and pragmatism21. Central in SI is the interdependence between subject and object in the understanding of meaning (Blumer, 1969). Woven through constructionism and SI is the idea of agency—that people have the capacity to interpret a situation and take action.                                             21 The roots of grounded theory (GT) are contested by one of the originators of the method, Barney Glaser. Several researchers in GT have successfully argued that symbolic interactionism and pragmatism were built into the foundations of GT through Anselm Strauss, the co-originator of GT. The writings of Charmaz (2006), as well as Milliken and Schreiber (2001, 2012) offer more in-depth accountings of the debate. 98  The interpretations people make are socially constructed and reflect cultural, political, and economic contexts, at the same time allowing individual differences in the meaning that is made. As such, researchers taking a constructionist stance, including SI, would acknowledge the historical, situational, and contextual influences on the research, and would view themselves as co-participants in the research and in the construction of knowledge (Lincoln et al., 2011). I took up a constructionist approach and operationalized that approach through GT, as it allows for the development of collective meaning but does not preclude the experience of the individual meaning-making and action-taking derived from that meaning. This perspective has important ramifications both for theorizing about how change may occur in the context of structure and agency in relation to moral distress, and for my choice of research methodology, which I will elaborate on in this chapter as well as in Chapter Four. What I take from Crotty’s discussion of constructionism is the idea that knowledge is constructed but does not preclude the belief in an obdurate reality; however, a constructionist position acknowledges the existence of multiple interpretations and meanings of reality (Crotty, 1998). Second, I understand that the idea that the theories derived from a constructionist stance reflect our experience of reality. Social constructionism, with its emphasis on understanding how culture shapes the collective development of meaning, simultaneously invites critique of what societies accept as truth and how they came to that truth. This kind of critique allows for the uncovering of the hidden assumptions and power structures that hold practices and beliefs in place. Once these 99  assumptions and power structures become transparent, choice, action, and change become possible (Kincheloe, McLaren, & Steinberg, 2011). This means that intentionally exploring how the health care context shapes the enactment of ethical practice may reveal avenues for the subsequent development of interventions that support HCPs in fulfilling their moral obligations to those in their care.When I move into the epistemological section of this chapter I draw on critical theory and relational inquiry as means of intentionally critiquing power within the health care system. Application of the Ontological Position Critical Inquiry The focus of my research is explicitly ethical and my purpose is to generate the understanding, beginning with this dissertation, that is the prerequisite for the creation of change in the health care environment. The research I conducted is necessarily one that critiques the relationship that exists between health care providers and health care organizations. The purpose of critical inquiry is to bring about social change. Critical inquiry, thus, is designed to seek understanding in order to effect change and movement toward a just society. By taking a critical perspective, I recognize the importance of context in shaping the understanding of, and the meaning that, situations have for the individual or actor. In order to bring about change using a critical lens, I examined cultural, and societal structures, and the assumptions that underpin structures and customs, through a variety of perspectives with the purpose of revealing the 100  power relationships that maintain the status quo. Examples of critical lenses are feminism, gender, discourse, and economics (Agger, 1998; Crotty, 1998; Denzin & Lincoln, 2011). In critiquing structures and assumptions for the purposes of change when I take a critical perspective, I necessarily reject a positivist stance and the belief in the existence of natural laws that determine human behaviour and the order of society (Agger, 1998). Instead, with a critical perspective, I hold to a belief that human behaviour, culture, and the social structures that exist at any given time in history are socially constructed and open to change. Thus, the purpose of critique from a critical perspective is emancipatory. It is a movement toward a just society through the raising of consciousness regarding oppressive structures and practices in the current age (Agger, 1998; Crotty, 1998). Beliefs about how change is brought about are reflected in the specific critical approach the researcher brings to the research. For example, some researchers believe that being involved in the research process itself will increase awareness for both the participant and researcher which would lead to change, whereas other critical perspectives may call for political action (Kincheloe et al., 2011). What this means for my study is that, while my purpose was to generate knowledge that would lead to interventions in moral distress, the process of engaging in the research may have created change for those involved in the study. Regardless of the specific critical perspective held by the researcher, the results that are hoped for include change that leads to transformation such as 101  emancipation, equity and social justice (Crotty, 1998; Denzin & Lincoln, 2011). In this study, I anticipated that using a critical lens would ultimately facilitate change by exposing some of the overt and covert power dynamics that exist within the health care system, and influence the behaviour, and expectations of both the employer and health care professionals. This examination of the power dynamics will also encourage the challenging of the assumptions that underpin, and hold in place, these dynamics, such as the neoliberal ideology that underpins current policy in health care service delivery. Also critical in recognizing the extent to which power influences choice and action within health care is the importance of understanding how health care professionals are relationally situated within their world, which, in turn, may enhance, or inhibit an HCP’s capacity to enact his or her moral agency. Therefore, in examining moral distress, it has also been important to explore the web of relationships in which each participant was situated. Relational Inquiry  I argued during the literature review (in Chapter Two) that people are shaped by both internal and external influences that impact their capacity for agency. External influences that affect a person’s capacity for decision-making and perspectives of personhood are relational in nature and include cultural, socioeconomic, and sociopolitical structures. In this context, I use the term relational to refer to the interpersonal relationships that an individual may take into consideration as they enact their decision-making. I also include the interpersonal relationships that influence the processes an individual engages in 102  as they make these decisions. In a feminist critique of the concept of autonomy, the philosopher, Sherwin (1998), outlined the implications of using a relational conception for understanding how social forces shape the development of self-identity that is instrumental in the enactment of moral agency. In what follows, I elaborate on how I used relational inquiry to enrich our understanding of agency. Feminist and other relational theorists have challenged the traditional view of an agent as an independent, self-determining individual who makes decisions based solely on rationality (Hoffmaster, 2001; Jaggar, 1991; Rodney, Kadyschuk, et al., 2013; Sherwin, 1998). Following the lead of such theorists, over the past two decades, scholars in nursing have explored what it means to be a moral agent from a relational context, acknowledging that individuals are contextually situated and that actions and decision-making are inseparable from context (Austin, 2011; Doane & Varcoe, 2013; Gadow, 1999; Rodney, Kadyschuk, et al., 2013). As I noted in Chapter One, the term “relational” is taken up in two distinct ways in the nursing practice and nursing ethics literature. The first way refers primarily to interpersonal relationships, or the quality of the relationships that exist between individuals (Bergum, 2013; Bergum & Dossetor, 2005). Bergum (2013) provides an example of “relational” with a focus on interpersonal relationships. In her discussion on relational ethics, Bergum focuses on the moral space that exists between people. She is also clear that focusing on interpersonal relationships as the place for moral action occurs at all levels of the health care system, stating that, “[e]thics at the bedside and ethics in the system are part and parcel of the same lived universe. The moral community includes 103  each of us as responsible for our actions in relation to the people we care for, educate, supervise, or work within partnership” (p. 128-9). Similarly, Jonsdottir, Litchfield, and Pharris (2004) recognize the interpersonal relationship, and the therapeutic relationship in particular, to be the core of nursing practice, and investigate ways to strengthen this aspect of practice. A difficulty with an exclusive focus on this interpersonal relationship perspective of relational inquiry is its emphasis on the individual nurse’s responsibility for developing and maintaining the therapeutic relationship, as well as for effecting change within the health care system (Doane & Varcoe, 2013). That focus is necessary, but not sufficient, to acknowledge how broader systems impact a nurse’s ability to form interpersonal relationships. The repercussions of focusing on the ability of the individual nurse is that the causes and experiences of moral distress can be viewed primarily at the individual level, leaving the health care organization absolved of its responsibility to provide an environment that supports nurses’ enactment of their moral agency as an intrinsic aspect of nursing care. The second way that “relational” has been taken up in the nursing and health care literature refers to the reflective examination of the multitude of factors that shape the relationship between the individual patient and the nurse (Doane & Varcoe, 2013). These factors include, but are not limited to, the context of the situation, the environment, and the sociopolitical and economic ideologies and power dynamics that influence health care delivery (Doane & Varcoe, 2014; Rodney & Varcoe, 2012; Sherwin et al., 1998). Viewing nursing and health care 104  provider practice overall from this broader relational perspective addresses the quality of the relationships that exist between individuals. Further, a relational perspective encourages us to examine how power is imbued in the health care system, and how that system supports or places barriers to the development of interpersonal relationships and health care practice in general.  In examining broader structural power dynamics, the responsibility for better health and health care outcomes shifts from being merely the responsibility of the individual care provider to being a responsibility shared, at least to some extent, with all stakeholders at all levels of the health care and social system. An example from mental health that may lead to moral distress is the development of the therapeutic relationship, or the relationship between an HCP and a patient that is focused on advancing the best interests of the patient. The obligation for developing the therapeutic relationship is that of the HCP and how he or she engages with the patient, as well as the responsibility of the health care organization to supply adequate resources so the HCP has the time to develop the therapeutic relationship.  My aim in this dissertation is to bring some conceptual clarity to our understanding of moral distress in order to move forward, in an intentional way, with the development of effective interventions. In order to accomplish this, I believe it is necessary to understand how structures and agents mutually influence each other in the enactment of moral agency, which necessitates the exploration of the meaning of moral distress of HCPs who have experienced it, and the critical examination of the sociopolitical structures that influenced the 105  experience. Grounding this research in the language of structure and agency conveys the idea of a belief in an obdurate reality, the belief that both structures and agents exist in the world. At the same time, understanding meaning and processes from the perspective of the participant upholds the belief that knowledge of the world is socially constructed. In applying a social constructionist lens to moral distress, I am not suggesting that moral distress is only socially constructed; I am, instead, arguing that the meaning given to the experience, and the subsequent action, is socially constructed. I also bring a critical perspective to this research in order to attend to the power dynamics existing within health care that influence decision-making and the maintenance of the status quo. Further, I conducted this research from a perspective of relational inquiry, as I believe that processes and meanings need to be understood in the context in which they were created.  In what follows I describe my research in the context of critical realism through my proposed use of critical theory and relational inquiry. Methodological Application: Critical Realism Understanding the relationship between ontology and epistemology is central to conducting research from a critical realist perspective. Bhaskar (1975) put forward a central argument in critical realism that science often conflates the object, in this case moral distress, under study with what is known about the object. Bhaskar seeks to shift our emphasis on knowledge from an epistemological focus to an ontological one (Nairn, 2012). In order to shift our 106  focus from how we might come to know an object to the object itself, Bhaskar states that, “Philosophical ontology asks what the world must be like for science to be possible” (p. 36). I thus examined moral distress from an ontological position starting with the question: “What must moral distress be for the experience to occur?” A critical realist approach to research is to theorize about the object under study and then to draw on the epistemological approaches that are best suited to investigating the theory (Nairn, 2012). McEvoy and Richards (2003) summarize four of the main features of critical realism, drawing on the work of the philosopher, Bhaskar. I present the features of critical realism, applying each tenet to moral distress to provide an example of how this approach helped to clarify the concept. The first feature is that of generative mechanisms. Critical realists view causality as complex and state that what is observed reflects generative mechanisms— structures, powers, and relations—beneath the surface that come together in a particular combination or context to generate an event (Bhaskar, 1975). In this way, generative mechanisms may be thought of as causal laws that exist in the natural and social worlds; however, their consequences are not always observed at an empirical level (Bhaskar, 1975; Blom & Morén, 2011). Instead, the effects of generative mechanisms are conditional, based on the surrounding context, and therefore may remain latent depending on circumstances (McEvoy & Richards, 2003).  Although generative mechanisms are not directly observable, they do exist and have an influence on the empirical world (Bhaskar, 1975; Blom & Morén, 107  2011; McEvoy & Richards, 2003). The purpose of research from a critical realist perspective is to theorize about generative mechanism and speculate about the conditions in which the generative mechanisms may be observed (Blom & Morén, 2011; Pawson & Tilley, 2004). The concept of moral distress provides an example of the complexity of causality. As I have argued earlier in this dissertation, although there is agreement regarding some of the contributing factors such as HCPs having an awareness of their moral obligation yet being unable to enact their moral agency due to constraints, researchers continue to grapple with how individual and structural factors come together to create moral distress in some situations and for some people, but not others (Austin et al., 2005; Hamric, 2012; Lützén & Kvist, 2012; Varcoe et al., 2012). The second feature of critical realism is the belief in a stratified ontology. In critical realism, reality is viewed as differentiated across two dimensions (Danermark, 2002). First, reality is stratified into three domains: a) the empirical, which we experience; b) the actual, where conditions come together but we may not see them; and c) the real, where generative mechanisms exist (Clark et al., 2008; Littlejohn, 2003; McEvoy & Richards, 2003; Wainwright, 1997). The second dimension of stratification occurs because reality is constituted of “hierarchically ordered levels where a lower level creates the conditions for a higher level” (Danermark, 2002, p. 57). However, the higher levels of reality cannot be reduced to the lower level components that make up the higher level.22                                             22 For further discussion of the stratified levels of reality in critical realism and how this is applied in moral distress research, please see Danermark, 2002 and Musto and Rodney, 2015. 108  Although critical realists assume an external reality, they reject a simplistic version of empiricism that limits reality to what can be experienced. Instead, critical realists assert that what can be experienced is “only a portion of what actually happens in the world. And what actually happens is only a small proportion of what could potentially happen, given the right combination of underlying mechanisms that exist in reality” (Littlejohn, 2003, p. 450). Critical realists accept that the underlying causal mechanisms may be complex and that a variety of conditions influence causal mechanisms in contingent ways, thereby changing the outcome at the level of observable events. The idea of causal mechanisms coming together in contingent ways has significant implications for researchers and knowledge development. One of the implications is that researchers ought not to look for strict regularities; rather, they should be looking for semiregular patterns, and underlying causal mechanisms (Angus & Clark, 2012; Clark et al., 2008). Another implication for researchers is in regards to assumptions; we cannot assume that because we don’t see evidence of moral distress at an empirical level, that it is not occurring at the actual level of reality. In terms of research on moral distress, there is a need to look for variations in the experience in order to theorize about the conditions and contexts that come together and influence the underlying mechanism to result in what is observed and experienced by health care providers. The third feature of critical realism that will support my study of moral distress is the dialectical interplay between social structures and human agency, 109  focusing on the interdependence of structure and agency (Archer, 2007; Clark et al., 2008; McEvoy & Richards, 2003) that I pointed to in my earlier discussion of Sewell (1992). From a critical realist perspective, social structures have the capacity to both inhibit and enable individuals to act through the distribution of resources, yet agents also have the capacity to influence these social structures (Nairn, 2012). In the context of moral distress, as I pointed to earlier, some of the external constraints that influence health care delivery include the discourse on economics, efficiency, and managerialism; however, health care providers respond in overt and covert ways that either support or interrupt these structures in an effort to create change (Rodney & Varcoe, 2012). It is my argument in this chapter that an important factor in developing conceptual clarity in our understanding of moral distress is a closer examination of the reciprocal relationship between social structures and the enactment of moral agency. That is, we need to understand better how agents can affect structures and vice versa, which is foundational to making constructive social change (Musto et al., 2015; Sewell, 1992). Finally, the fourth feature presented is a critique of the prevailing social order (McEvoy & Richards, 2003, p. 412). Cruickshank (2012) identified the use of critical realism as a means of criticizing illegitimate practices and of improving existing theories through criticism. McEvoy and Richards also note that, although taking up critical realism does not necessarily “entail a commitment to a specific theory or sociopolitical agenda” (p. 413), critical realism can be used to examine how structures maintain social inequities. In health care, these structures include 110  the discourse of reductionist demands for a cost effective and efficient health care system. For the purpose of examining the complex phenomenon of moral distress, I took up a critical perspective in my analysis to examine the structures in which health care is provided, with attention to the power relationships that influence the delivery of care. Bridging Post-Positivism and Constructionism The examination of power relationships within structures assumes that power both shapes human behaviour, and that a power balance is dynamic and can be shifted or changed. Some of the questions relevant to my use of critical realism in this research were related to how critical realism bridges the gap between post-positivism and constructionism. In positioning critical realism, proponents draw on the strengths of positivism and constructionism, yet, at the same time, they reject the limitations of each paradigm (Clark et al., 2008; Cruickshank, 2012). Some adherents of critical realism place it within a post-positivist paradigm (Cruickshank, 2012), while others position it beyond post-positivism by setting out “a much more distinctive alternative to positivism and relativism” (McEvoy & Richards, 2003, p. 412). Critical realism shares a positivist foundation with post-positivism; however, it moves beyond post-positivism and the critiques of positivism by explicitly incorporating constructionist approaches into its perspective on truth and the production of knowledge (Clark et al., 2008; McEvoy & Richards, 2003; Nairn, 2012). 111  In constructionism, the meaning of an object is conferred upon an object through interaction (Crotty, 1998). Of note to critical realism in the preceding statement is that objects exist regardless of our knowledge of them, but it is through interaction with the object that it comes to hold a particular meaning for people. Meanings, and by extension knowledge, are socially constructed, therefore they are historically, politically, and culturally situated. Thus, knowledge is considered contextual and evolving (Crotty, 1998). Critical realists recognize the importance of understanding how context influences meaning in the construction of knowledge; this applies across both the natural and the social science worlds (Bhaskar, 1975). Understanding context is key when using a critical realist approach because of the recognition that generative mechanisms are activated or not activated, depending on context. Pawson and Tilley (2004) describe a critical realist approach to program evaluation that utilizes “contextual thinking to address the issues of ‘for whom’ and ‘in what circumstances’ a programme will work” (p. 7). Taking into consideration the constructed nature of knowledge, and understanding the contextual influences on moral distress through my use of critical realism in this research, will help researchers accurately theorize about the conditions that give rise to the experience, which Hamric (2012) notes that such theorizing is a prerequisite to developing targeted strategies to intervene. Understanding the meaning HCPs attribute to situations in which they feel constrained or supported in the enactment of moral agency, and theorizing about 112  these conditions, were central to my considerations regarding choice of methodology. Some of the concerns with constructionism expressed by critical realists include a structuralist position and the potential for relativism, whereby knowledge is held to be subjective and individual (Wainwright, 1997). A constructionist approach to knowledge development, if taken to an extreme, includes the belief that individuals are not only socially constructed, but that they are determined by social structures. To counter this claim, critical realists point to the reciprocal relationship between and among individuals and structures, stating that social structures emerge from “the actions of individuals and then exert a causal influence over individuals” without determining them (Cruickshank, 2012, p. 73). In positioning moral distress within a critical realist perspective, I am claiming that moral distress is underpinned by generative mechanisms and that it exists regardless of our knowledge of it. This means that I view moral distress as existing but not necessarily activated unless aspects of the internal and external environment come together in a particular way to activate moral distress. In this way, the experience of moral distress is activated and observed at the empirical level in the context of the reciprocal relationship between structures and agents. Foundational to the belief that there is a reciprocal relationship between structure and agency is accepting that structures and agents are both open systems with the capacity to change and be changed (Bhaskar, 1975; Pawson & Tilley, 2004). Notwithstanding its ground-breaking importance, in the original definition of moral distress, Jameton (1984) somewhat naively suggested that 113  nurses were unable to enact their moral agency when confronted by external constraints. As I have argued in Chapters One and Two, understanding the relationship between structures and the enactment of moral agency continues to be problematic. In more recent research on constrained agency, Rodney and Varcoe (2012) argued that nurses take both overt and covert action when confronted by situations and policies driven by sociopolitical ideology that inhibits their ability to provide care in the best interest of the patient. Although moral distress was not the main focus of their work, moral distress emerged as a consequence of efficiency-driven policies for the nurses in their studies. As well, the nurses’ response to these policies demonstrates that nurses, as agents, find creative ways to respond to situations that challenge their moral obligations to the patient, and these responses were not necessarily pre-determined by these structures. For example, in their study, Rodney and Varcoe noted that some nurses actively defied policy that interfered with their ability to provide good care (2012). It has been my premise in this study that applying a critical realist lens to the examination of the reciprocal relationship between structures and agents allows researchers to view the relationship as dynamic, and encourages a greater understanding of how the interplay between structure and agency may create change.   The second concern with a constructionist approach is that of relativism. While not all knowledge that is constructed is subjective (Crotty, 1998), critical realists argue that, when taken to the extreme, if knowledge is seen as only socially constructed, then there can be no truth claims because truth becomes 114  relative to a particular individual or group (Clark et al., 2008; Wainwright, 1997). Although critical realists reject relativism, they endorse the importance of understanding meaning and the social context in which knowledge is developed; as such, knowledge is perspectival, open to questions and to change (Clark et al., 2008; Nairn, 2012). In drawing on the strengths of each paradigm, critical realists claim the middle ground between paradigms (Clark et al., 2008).  Throughout this section, I have pointed to a need to understand the contexts and conditions that contribute to moral distress, as well as to understand the meaning HCPs ascribe to these situations to gain greater insight into the idea of constraints. In order to answer my research question, I therefore sought a methodology that would be able to attend to the meaning and practical application simultaneously. Toward an Ontology of Moral Distress. As I have explained in this chapter, I used a critical realist approach for my study in order to move toward a definition of moral distress that could account for the complexity of the conditions that contribute to and influence the experience of moral distress. This required shifting from an epistemological focus on moral distress to an ontological perspective.  That is, I wanted to shift perspective from an epistemological focus on developing knowledge about moral distress to an ontological perspective that focused on what moral distress must be like. This required moving beyond a descriptive focus on moral distress to understanding the experience as being emergent through interaction between, and among, 115  structures and agents. In what follows, I describe the features of critical realism that support the study of moral distress from the place of seeking to understand the phenomenon itself, rather than what can be known about the phenomenon at an empirical level.    Since Jameton identified the concept 30 years ago, nurse researchers have investigated the experience by trying to discern how we know an individual is experiencing moral distress. While this information can give us important insight into recognizing moral distress, it does not give us insight into what moral distress actually is. In critical realism, Bhaskar (1975) refers to this as an epistemic fallacy, which arises when what is known about a phenomenon is conflated with the entirety of the phenomenon (Angus & Clark, 2012). From empiricism, the epistemic fallacy is revealed in the assumption that what can be known about a phenomenon, and the causal mechanisms underlying the phenomenon, can be defined through the observation of fixed patterns.  If I were to apply this assumption to the concept of moral distress, in situations where there are external constraints, such as understaffing or policy initiatives that compromise a nurse’s ability to provide care in the best interest of the patient, and the nurse is unable to act, I would expect nurses to exhibit symptoms of moral distress.  However, this is not always the case, as other outcomes, such as moral disengagement, may occur (Rodney, Kadyschuk, et al., 2013). This dissertation research was based on the premise that we need to explore moral distress from an ontological position of speculating about what moral distress might be, rather than from an epistemological position of how we 116  can come to know the experience of moral distress (Bhaskar, 1975).  In was also my premise that an ontological approach to understanding moral distress would enable researchers to theorize about the dynamic relationships between the external structures of health care delivery and the internal context of the moral agent.  Thus, future researchers may be able to develop interventions that support health care providers to move toward taking action to support their moral obligations to the patient before the consequences of moral distress are seen at an empirical level.  In summary, as I have argued at the outset of this chapter, for this study, critical realism provided an ontological foundation that allowed a rich, nuanced, understanding of the conditions that contribute to moral distress, and critical realism provided a framework for theorizing about how the interaction between these conditions may result in moral distress. As a consequence of this study, it has been my intent that future researchers will be able to plan effective interventions in helping HCPs work through the experience. In moving toward an articulation of my methodology, I begin by examining the tenets and underpinnings of critical realism, including examples of how this approach may inform our understanding of moral distress. Methodological Pluralism in Critical Realism Theories developed using critical realism are based on generative mechanism(s) that underlie causation, and these mechanisms are often not easily amenable to direct study (Angus & Clark, 2012). As well, one of the 117  consequences of prioritizing ontology over epistemology, as Nairn (2012) claims, is that it offers “a route into a relational approach to knowledge that incorporates a pluralist approach to finding out about the world alongside a realist commitment to the structural properties of both the natural and the social worlds” (p. 7). This relational approach acknowledges the interplay between and among the biological, psychological, and social structural factors that influence outcomes in research (Nairn, 2012), and is consistent with my theoretical commitments in this research. In a health care context, acknowledging this interplay in research may more accurately reflect what takes place in the world, but it becomes difficult, if not impossible, for one research methodology to attend to this complexity. McEvoy and Richards (2003) point out that in critical realism the primary concern is not the methods of investigation; rather, it is how these methods are used. Generating Theory in Critical Realism.  The job of researchers using critical realism is to develop theories that can explain the causal mechanisms that lay at the real level of ontology beneath what is observed at the empirical level (McEvoy & Richards, 2003). These theories need to account for the conditions and contexts at the actual level of ontology that influence what may, or may not, be experienced at the empirical level (Wainwright, 1997). Wainwright identifies three keys for a realist explanation: “(1) the postulated mechanism must be capable of explaining the phenomena; (2) there must be good reason to believe its existence; and (3) there should be no equally good alternatives” (p. 1265). McEvoy and Richards (2003) describe theory development in critical realism as retroduction, a form of creative 118  reasoning. Retroduction involves observation and developing a theory to explain the observations. They liken the process of retroduction to that of detective work, whereby the detective solves a crime retrospectively by reading the signs that accompany the crime. Using the idea of retroduction and drawing on the concept of a stratified ontology, I will reached across disciplines and speculated about how the contexts and conditions discussed in the literature review may come together in a contingent way and lead to the experience of moral distress. Given the emphasis on the contingent nature of reality in critical realism, developing theory requires seeking out variation in order to account adequately for the observed outcome(s) (Pawson & Tilley, 2004). GTM also encourages the researcher to seek out variation in order to develop a theory that can account for a wide range of experiences. I elaborate on GTMs in Chapter Four. In critical realism, by intentionally seeking out variation, the ensuing theory has greater capacity to explain how contexts, and under what conditions, generative mechanisms will be activated. Seeking out and examining variation in health care providers’ experience of moral distress may help explain why certain situations lead to moral distress and others do not. Indeed, researchers using GT methodology seek out variation in the experience under study in order to account for the contexts and conditions that contribute to, or influence, the situation. Such has been my intent in this dissertation research. It is important to note that GT is not the only methodology that is consistent with critical realism. Examples of approaches used for research from a critical realist perspective include using qualitative and quantitative methods such 119  as structured or semistructured interviews, participant observation, cluster analysis, GT and regression analysis (Clark et al., 2008; Cruickshank, 2012; Jantzen, 2012; McEvoy & Richards, 2003). As well, McEvoy and Richards state that critical realists have taken traditional methods of inquiry, such as a systematic review, and applied them in new ways. For example, Pawson (2002) provides an example of a systemic review using a critical realist approach wherein synthesis of data is based on “generative mechanisms” and its “contiguous context” (p. 342). Finally, from the field of social work, Blom and Morén (2011) have developed a model to assist researchers in identifying, describing, and conceptualizing generative mechanisms.  Although theorizing in critical realism provides opportunity for the development of a richer understanding of context and conditions that lead to moral distress, there are also critiques I needed to attend to in order to to clarify my theoretical and methodological approaches in a credible way. In what follows, I discuss the critiques of theorizing in critical realism and include the addition of critical and relational inquiry lenses as a means of navigating these critiques. Critiques of theorizing in critical realism.  Researchers in the social sciences have used a critical realist approach in order to explore complexity and to examine more process-oriented questions in their areas of study (Blom & Morén, 2011; McEvoy & Richards, 2003). More recently, researchers in nursing are being challenged to use critical realism to demonstrate the complexity that exists in developing effective health care policies, programs, and interventions in achieving positive outcomes, as well as 120  to conduct research for knowledge development in nursing (Bergen, Wells, & Owen, 2008; Clark et al., 2008; Littlejohn, 2003; McEvoy & Richards, 2003; Wainwright, 1997). To this end, nursing researchers have applied critical realism to research and theory development (Bergen et al., 2008; Littlejohn, 2003), policy reform/evaluation (McEvoy & Richards, 2003), theory-driven program evaluation (McEvoy & Richards, 2003; Pawson & Tilley, 2004), and improving knowledge translation, chronic disease management, and public health (Clark et al., 2008), to name a few areas. As I have indicated in the preceding chapters of this dissertation, there has been a call by researchers to clarify the concepts underpinning the definition and experience of moral distress, and for the development of effective interventions. I assert that acknowledging the complexity of moral distress at the nexus between structure and agency is central to clarifying the underpinnings of moral distress. Critical realism offers an approach to both explore the relationship between structure and agency, and to theorize about this relationship. The focus of my research question was on the interaction between HCPs and the context in which they work. This focus on process went beyond a descriptive study to examine processes that are not directly observable. GT, with roots in symbolic interaction and pragmatism, has been well suited to the examination of process and theorizing about action. Critical realism and the belief in a stratified ontology allowed me to theorize about the complexity involved in the experience of moral distress. In Chapter Four, I elaborate on the use of GT as my methodology for this study.   121  As I have indicated throughout this chapter, applying a critical realist perspective to theory development in moral distress enabled me to move beyond examining moral distress at an empirical level to theorizing about underlying factors that contribute to the experience at the actual level of ontology. The resultant theory illuminates the contingent ways in which these factors come together. The potential for theory development in moral distress notwithstanding, it is important to note that several authors have expressed concerns about the nature of theorizing in critical realism. First, due to the ability of critical realism to allow the exploration of complexity, Angus and Clark (2012) pose the question: “how much complexity is too much complexity given the constraints of what is currently possible, feasible, and acceptable?” (p. 2). Second, these concerns have included recognition of the difficulty in identifying generative mechanisms (Angus & Clark, 2012; McEvoy & Richards, 2003). Finally, McEvoy and Richards (2003) note that there is potential for these theories to drift across scientific demarcations to political ideology. Given these concerns, it has been important to develop research strategies that support the identification of generative mechanisms, as well as the means to study these mechanisms (Angus & Clark; McEvoy & Richards). Also, in regards to the concerns about theorizing, the methods of GT are designed to help researchers develop a theory that arises out of the data. I explain these methods further in Chapter Four. 122  Summary of Implications for Moral Distress Research My research question was directed toward conducting a critical examination of the concept of moral distress and the environment in which it occurs. Relational inquiry fostered an intentional consideration of how interpersonal and structural relationships may shape the research participant’s ability to enact moral agency within the health care system. Taking up a critical and relational approach to this study reflected a belief in the capacity for change, and that change in either the agent or health care structures is an iterative process. More specifically, framing the research process within a critical realist perspective guided me to move beyond a linear cause and effect explanation, to explore the layered, and complex factors that contribute to the experience. Exploring moral distress in a context that embraces complexity helped clarify how aspects of the health care environment interact with personal attributes of the individual to influence the experience of moral distress.  By embracing complexity and clarifying the underpinnings of moral distress, researchers have the opportunity to subsequently develop interventions that support reflective moral practice and positive health outcomes for HCPs and patients.  Incorporating a critical perspective with relational inquiry in the research fostered an approach that extends the study beyond the individual health care provider to encompass the sociopolitical structures in which health care is delivered.  The subsequent clarification of the attributes that contribute to 123  moral distress at both a structural and agent level facilitates the eventual development of intentional and multilevel interventions.  In summary, given my desire to eventually move toward practical interventions in moral distress that can be trialed within the health care system, I chose to use constructionist grounded theory to conduct this research. As I considered my research questions and the purpose of the research in order to make a decision regarding methodology, I recognized that I wanted a methodology that reflected  attention to the process(es) that are present as individuals attempt to work through a situation;  attention to the structural processes and conditions that influence the situation;  attention to how the meaning attributed to the situation influences action;  the ability to explain variation in the experience;  the ability to provide an explanation for what is going on in the situation; and  an explanation that could underpin a framework for interventions. The purpose of GT research is the development of a theory that explains a pattern of behaviours or actions participants engage in to resolve a problematic situation (Glaser, 1978; Schreiber, 2001b).  GT incorporates the elements listed above, and the resultant theory generated from this dissertation research will inform potential avenues for intervention.  In the following chapter, I provide a background to the philosophical roots of GT, outline the grounded theory process 124  in developing a substantive theory, and describe my approaches for recruitment, data collection, and data analysis.   125  Chapter Four: Methodology Choosing a research methodology is a reflection of both the research question and of the philosophical positioning of the researcher (Charmaz, 2011; Thorne, 2008). The question for this study centers on examining the processes HCPs working in mental health care engage in as they seek to enact their moral agency. I have studied these processes in a way that examines the reciprocity between structure and agency. The research question itself frames the particular interest a researcher has in a substantive area, and what is seen in the data that informs the findings. As such, the purpose of this chapter is to make the connection between my research questions and GTM. To accomplish my purpose, I outline my reasons for choosing grounded theory to answer the research questions. I do this by providing a brief reminder of the research problem, situating myself, along with the problem, within a constructionist paradigm, and then sketching out the history and context of grounded theory, along with the philosophical assumptions underpinning GTM. I then provide an overview of the methods and techniques and how they were used in this research. Review of the Research Problem and Questions  As a starting point, I reviewed the introduction of moral distress to nursing literature, and the subsequent development of knowledge regarding the concept, ending with a critique of the concept and our current state of knowledge 126  regarding moral distress in Chapter Two. Although our understanding of moral distress has increased, a significant critique of the state of current knowledge on moral distress is that it lacks conceptual clarity. As I explained in Chapters One and Two, I have, therefore, taken up this challenge. I have drawn on research from across disciplines to create a conceptual framework for understanding moral distress as an embodied experience that is shaped by a reciprocal relationship between structures and agents. It is this reciprocal relationship that I intended to examine empirically through my dissertation work. Framing moral distress in the context of the reciprocal relationship between structure and agency allowed me to attend to structures, both formal and informal, as well agents, in exploring how the environment interacts with the HCP to facilitate or constrain moral agency in the context of the provider’s fiduciary responsibility to the patient. Based on my practice experience, I made an assumption that moral distress occurs in the context of balancing fiduciary responsibilities to patients within the current health care environment. From this perspective, I aimed to conduct a qualitative study to investigate the processes HCPs engage in, as they balance these responsibilities while navigating the reciprocity of structure and agency. The specific research question I intended to answer was: How do HCPs in mental health care navigate morally charged situations and enact their moral agency within their health care organizations? 127  The research question reflects a desire to understand the processes HCPs engage in as they attempt to balance competing tensions between the needs of health care organizations and professional values. In addition, we know that the nature of the work in mental health care is process-oriented, and attends to factors in the environment that maintain, facilitate, or inhibit the development of protective factors and resiliency. Thus, the research methodology I chose for my study would have to also attend to context and process. In reviewing constructionism, SI, critical realism, critical inquiry, and relational inquiry in Chapter Three, I saw similarities in the assumptions underpinning these perspectives. Common to all of these perspectives is attentiveness to the relationship between structure and agency, and recognition that knowledge is constructed and situated in a historical, cultural, sociopolitical context (Agger, 1998; Crotty, 1998; Doane & Varcoe, 2013; MacDonald, 2001; Nairn, 2012). Because knowledge is constructed and situated, the meanings attributed to situations are multiple, allowing complexity, and variation. In the following section, I provide my rationale for situating this research within a constructionist paradigm and for my choice of GTM. Situating Myself and the Research As I indicated at the outset of this Dissertation, my journey toward becoming a researcher began as I struggled to reconcile what I have come to understand as the moral and ethical aspects of nursing with the reality of daily practice. In framing the research problem within the relational context of structure 128  and agency, the focus of my research was on the complex interplay of meaning, context, and process. I believed that a qualitative research approach is best suited to answer questions about complex processes. Aligning the ideas of relational ethics and moral obligations with research exploring meaning, context, and process, directed me to examine transformative research methodologies that explicitly recognize the partnership between the researcher and the participant, and that acknowledges context (Anderson, 1991; Freire, 2010). Consequently, I situated myself within a qualitative paradigm and took a constructionist position to explicitly foster collaboration between researcher and participant, because this reflects the complexity of the research question, while also laying a foundation for the later development of interventions. In stating that truth is constructed, my position is that our understanding of reality is influenced by the social structures in which we live. As well, in aligning with GTM, I aligned with the normative aspects of qualitative research and understood that facts and values cannot be fully separated (Charmaz, 2006, 2011; Jameton & Fowler, 1989). Consistent with the application of constructionism to the research question that I articulated in Chapter Three, I emphasized that actions cannot truly be understood outside of the context in which those actions occurred. The purpose of this study was to develop depth in our understanding of how environmental and individual characteristics interact with and influence the experience of moral distress, as well as the factors that support or impede the HCP’s ability to enact moral agency. This study can help clarify some of the constructs contained in the original definition of moral distress that, up until now, 129  have interfered with our ability to come to a collective understanding of the concept (McCarthy & Deady, 2008; Musto et al., 2015; Pauly et al., 2012). When I started out with this research, some of the constructs I had planned to explore included the role of taking action in the experience of moral distress, the embodied nature of the experience, and the interplay between the health care environment and the HCP that contributes to the perception of constraints and supports in the enactment of moral agency. Given the need to clarify some of the constructs of moral distress, as well as to explore factors that influence the experience, I chose to examine the processes HCPs engage in when making ethical decisions and having to balance competing values. By adopting a critical realist approach, I recognized that the layered and contingent nature of reality required analysis of the underlying processes of moral decision-making and meaning-making. Examining these processes required that I explore, and try to understand, the meanings people, in this case HCPs, applied to an ethically challenging situation, and the role those meanings played, in order to understand the resulting action. GT is a research methodology that is focused on understanding social processes, and discovering the basic social process that lies at the center of action and brings about change (Glaser, 1978). It was also important that I examine the competing elements that influenced the context within which the HCP made decisions. As such, I determined that a qualitative approach was best suited to this research and that GT offered the requisite tools for the exploration of process and the understanding of meaning. 130  Origins and Evolution of Grounded Theory Methodology Historical Background In Chapter Three I outlined the theoretical approaches that framed this research and explained why I believed a constructionist position was best suited to answer my research questions. In this section, I provide a brief background for its development, and then trace the evolution of GT, eventually landing in a constructionist perspective. The historical context and epistemological debates within the discipline of sociology deeply influenced the explication and development of GT (Bryant & Charmaz, 2007a). In this section, I discuss these origins, beginning with a brief look at the historical context from which GT grew. I then review the academic traditions that Glaser and Strauss brought to the development of GT methodology; these traditions are positivism, SI, and pragmatism. Following a review of Glaser and Strauss, I discuss contemporary GT in the form of constructionist grounded theory and situational analysis. Finally, I provide a summary of grounded theory methods to develop theory from data. The historical impetus for grounded theory. Barney Glaser and Anselm Strauss developed the grounded theory methodology in the 1960s, in part, as a response to the positivist culture that permeated the discipline of sociology. Glaser and Strauss first published their book, Discovery of Grounded Theory in 1967. Although they came from divergent philosophical backgrounds—Glaser from a positivist perspective and Strauss from a symbolic interactionist (SI) and pragmatist perspective—the purpose of their collaboration was to aid researchers 131  in the generation of theory (Glaser & Strauss, 1967). Glaser and Strauss expressed concern with what they saw as a focus on verification of existing theories, and the development of theories based on a-priori assumptions that were not grounded in the reality of what was actually happening in the situation (Bryant & Charmaz, 2007b; Glaser & Strauss, 1967). As a response to these shortcomings, they advocated for a shift in the focus of research away from verifying existing theory to that of generating new theory based on data. Thus, in Discovery of Grounded Theory the authors outlined the process involved in creating a theory that was rooted in the data, and exhorted sociologists to return to their primary mandate of developing sociological theory that was exciting and relevant (Charmaz, 2006; Glaser & Strauss). Significant to the emergence of GTM is a recognition of the historical context in which Glaser and Strauss formed their partnership. As noted, Glaser and Strauss (1967) were responding to an emphasis on the need to verify theory in sociology. Verification of theory was a reflection of a belief in the supremacy of the positivist ideology inherent in quantitative research (Charmaz, 2006). In providing a coherent monograph that outlined the methods they used for the development of theory in their own research, Glaser and Strauss (1967) hoped to provide qualitative researchers with a systematic method for collecting and analyzing data in the process of generating theory. In doing so, they aimed to bring legitimacy to qualitative research. They also hoped to provide a rejoinder to critics who claimed that findings from qualitative research were not scientific enough for developing theory (Bryant & Charmaz, 2007a). Although Glaser and 132  Strauss created a research methodology that appeared to bridge the qualitative/quantitative divide, their philosophical origins eventually took them in separate directions and fostered an ongoing schism in GTM, leading to a variety of approaches (Milliken & Schreiber, 2012; Schreiber & Martin, 2013). In what follows I will provide an overview of that schism and justify my own commitment to a constructionist approach in this research. Positivist grounded theory. Individually, Glaser and Strauss continued to use and develop grounded theory as a research methodology; however, each author applied GT in a way that reflected the tradition from which they came. Glaser says little about the philosophical roots of GTM (MacDonald, 2001), however, he is clear that GTM is a methodological approach that provides a systematic method for data collection and analysis, based on quantitative analytic methods (Charmaz, 2006; Stern & Covan, 2001). When Glaser (2006) does provide his view on the roots of GTM, he does not discuss the philosophical underpinnings; rather, he refers to the “four dimensions of doing sociology—autonomy, originality, contribution and the power of sociology” (p.1). In describing GTM methodology, Glaser states that, “GT is just a simple index formation, inductive method based on using any type of data” (p. 3). Even if the philosophical underpinnings are unstated, the initial and subsequent language used by Glaser to describe the process of doing GTM, and the development of a substantive theory, very much fall within a positivist tradition. Although others argue that GT is falls with a post-positivist paradigm (Hall & Callery, 2001) Glaser’s writings convey a belief in an external reality that can be discovered, or 133  will emerge from, a careful analysis of the data (Bryant & Charmaz, 2007a). In refuting the idea of GTM as constructionist, he affirms that a researcher need not be concerned with concepts such as bias, because she or he is only identifying patterns that exist in the data (Glaser, 2002). Social constructionist grounded theory. Strauss came out of an academic tradition that included symbolic interactionism (SI) and pragmatism. As a symbolic interactionist, Strauss emphasized the importance of understanding social processes as central to theory development. In attending to social processes, Strauss drew on SI and pragmatism (Strauss, 1995a, 1995b). SI is an approach that seeks to understand “human group life and human conduct” (Blumer, 1969, p. 1). The three core premises of SI identified by Blumer include: a) humans act toward things on the basis of the meaning things have for them; b) meaning arises out of social interaction; and c) meaning is handled in, and modified through, interpretive processes. While acknowledging the existence of an obdurate reality (Blumer, 1969), it is within the context of social interactions that meaning is constructed, and meaning can only be understood through direct examination of the social world. Blumer’s premises also make explicit the actor’s role as a thoughtful, conscious agent, actively making meaning, and choosing action in the social interaction, thus illuminating the reciprocity that exists between structure and agency pertinent to my research. In focusing on the need to understand meaning, and the context that shapes meaning, Strauss began to move GT away from positivism toward a constructionist paradigm. 134  Contemporary Grounded Theory Constructionist grounded theory. As a student of Strauss, Charmaz (2006) moved GT further along the continuum of qualitative research. Within an interpretive paradigm, there exists a belief about knowledge production—in this case theorizing—as being situated within the context in which it is produced (Charmaz, 2006; Lincoln et al., 2011). Therefore, not only is the subject of the research contextually situated, but the knowledge produced through GT is also contextually constructed, and is influenced by historical, cultural, and social situations. Importantly, facts and values are seen as inseparable (Charmaz, 2006, 2011). What this means for theorizing is that the researcher is a co-constructor of knowledge and an active participant in the development of the theory. In the context of values central to this dissertation, the values of the researcher directly influence what the researcher will attend to in the data. In taking the stance that the researcher is an active participant in the research, Charmaz effectively cuts the ties with positivist assumptions that the researcher is an objective bystander, who has no influence on the data or the emerging theory. I used Charmaz’s approach in GT for this research. Charmaz calls her approach constructivist grounded theory. Although Charmaz (2006) clearly locates constructivist GT within an interpretivist paradigm, she also claims that a constructivist view assumes an obdurate reality, acknowledging an ever-changing world with multiple and diverse realities. Thus, while cutting ties with the positivist underpinnings evident in early GT, Charmaz remains firmly 135  connected to the local context that shapes behaviour, meaning, and action. In my review of her method, I found it to align with my definition of constructionist as outlined in Chapter Three. As such, I consider Charmaz’s approach to be constructionist and will refer to it as constructionist throughout this Dissertation. Charmaz, along with Glaser and Strauss (1967), states that GTM can support the development of both substantive and formal theory, depending on the level of abstraction of the theory, meaning that GTM allows the exploration of how people’s actions affect their local and larger world (Charmaz, 2006). This stance is relevant for my study, because one of my purposes is to examine the interplay between structures and agents, and an assumption I hold is that action at a local level can influence structure at a broader level. Summary of GTM for This Study. In developing GTM, Glaser and Strauss (1967) argued that the major task of sociologists was to develop a theory that fits the situation, is immediately understandable, and provides a relevant explanation. In order to accomplish this, Glaser and Strauss developed methods that supported researchers in data collection, coding, and theory development, so that the theory arose out of the data. The actual process of GTM research is comprised of common strategies, and includes: concurrent data collection and analysis; theoretical sampling to direct ongoing data collection and to elaborate categories; memoing of ideas, linkages between categories, and the tracking of research decisions; and diagramming. In using GTM to examine how HCPs navigate ethical situations in 136  the current health care climate, I developed a theory that is contextually relevant, and that sets the stage for future development of interventions that support the enactment of moral agency. Conducting Grounded Theory GTM helped me answer my research question centered on the enactment of moral agency within health care structures. There are strategies common to conducting all GT research that reflect its focus on processes, regardless of the ontological position of the researcher. I drew on these strategies for data collection, analysis, and theory building, to explore HCPs’ enactment of moral agency. In this section, I outline the progression of my study, beginning with the inclusion and exclusion criteria for participants. I then discuss the concept of sampling in GTM. I provide a description of the participants, and my recruitment strategies. Following this, I discuss my methods of data collection and data analysis, which included memoing, constant comparison, and coding. Finally, I describe rigor for GT and how the resulting theory can be evaluated. Inclusion criteria. The criteria for this study included HCPs from across mental health professional disciplines, such as social work, nursing, and occupational therapy. Participants could work at different levels of patient care—including providing direct patient care—or work at different levels of leadership. To try and understand how health care providers enact their moral agency within health care structures, I recruited participants who identify with the experience. To this end, I recruited HCPs who had worked in the health care system for a 137  minimum of six months, belonged to a regulatory body, and had an interest in discussing how they navigated ethically challenging situations in mental health care as evidenced by their agreement to participate in the study. Exclusion criteria. There is some literature suggesting that moral distress is experienced by people working in health care that are not part of regulated professions. However, I am excluding unregulated providers from this research. Regulated professionals are held accountable to a professional Code of Ethics and Standards of Practice, and thus have an added layer to ethical decision-making. Literature in moral distress suggest that aspects of the experience may be related to health care professionals being unable to provide care according to their ethical obligations and Standards of Practice (Peter & Liaschenko, 2013); Thomas & McCullough, 2015). Sampling As I reviewed the different sampling strategies used in qualitative research in general, and GT in particular, it was apparent that the sampling process changes from an initial purposive sampling to theoretical sampling,23 which is ongoing throughout the development of theory. For qualitative research, the principle guiding the selection of participants on initiation of the study is to seek participants according to the aims of the study (Coyne, 1997). Charmaz (2006)                                             23 Purposive sampling refers to choosing a sample the researcher believes best fits the needs of the research, and as such, sample selection is not random (Polit & Beck, 2008), which is where GT begins. However, ongoing sampling is purposeful and attends to the theoretical concerns developing in the theory (Charmaz, 2006) 138  describes initial sampling in GT as the place to start in order to get relevant information for a study; as such, the researcher will want to identify ahead of time the group of people that will most likely be able to provide this information (Thorne, 2008). The criteria for selecting participants are established before the study begins and may include such things as age, gender, status, and role in the organization, or location (Coyne, 1997). For my study, I began with purposive sampling, and initially recruited participants who self-identified as having experienced attempting to navigate ethically challenging situations in acute mental health care. As the study proceeded and data was analyzed, I used theoretical sampling to guide further data collection, which I describe in further depth in the next section. Sensitizing concepts. A sensitizing concept is a concept the researcher brings in to research with himself or herself (Schreiber, 2001b). The current literature on moral distress provided some sensitizing concepts I used for direction with regard to participants and sources of data (Thorne, 2008). Research findings suggested that resource allocation, ambiguous policy, or lack of policy may be complicit in the experience of moral distress (Burston & Tuckett, 2013; Musto & Schreiber, 2012), and contribute to ethically challenging situations. A caution for the researcher that accompanies the idea of sensitizing concepts is that they may blind the researcher to other concepts in the data (Schreiber, 2001b). In the context of sampling and recruitment, I needed to take steps to remain open to what is in the data and not simply look for what I expected to find. I did this by making my own ideas and assumptions explicit 139  through memoing, a GT technique (Schreiber, 2001b). This caution speaks to the credibility of the research; I elaborate on strategies regarding rigor and credibility later on in this chapter. Sample Size In Discovery of Grounded Theory (1967), Glaser & Strauss claim that it is impossible to know beforehand how many participants will be required in order to achieve theoretical saturation and develop a theory that will answer the research questions. With this in mind, Charmaz (2006) and others suggest that the considerations for sample size also include the purpose of the study, the qualitative method being used, and the resources available to the researcher (Sandelowski, 1995; Thorne, 2008). I anticipated that 20 to 30 participants were needed in order to understand adequately how HCPs enacted moral agency in their particular context. By the end of the study, I had interviewed 27 participants. Location My study took place at two urban sites located in the lower mainland of British Columbia. The locations were chosen for several reasons: they each contain several inpatient acute care psychiatric units and have a large staffing pool. Moreover, I had access to potential key contact persons in both locations, either through personal connection, on the basis of my past professional work, or through members of my supervisory committee. Establishing connections within each site helped facilitate trust and credibility as I began the recruitment process. 140  Both sites were within a reasonable distance to me, either by car or transit, thereby keeping costs of the research at a manageable level. The use of two sites also provided a level of confidentiality for participants. This study began once ethical approval was obtained at each these sites and at the University of British Columbia. I anticipated that one site (Site A) would be considered the primary site where most of the data collection would take place. The second location (Site B) would be used to enrich my observations, fill out developing categories, and elaborate the theory. In fact, recruitment and data collection occurred consecutively at each site, and data from both sites were used equally for theory development. Gaining Access and Recruitment Currently, in acute care psychiatry, care is delivered through a multidisciplinary team that draws on the disciplines of medicine, nursing, social work, psychology, and occupational therapy, to name a few. The sites I selected were in urban locations, had extensive inpatient mental health services, and employed a range of disciplines for the provision of treatment. Therefore, these sites afforded me access to a large contingent of staff across disciplines that provide care to diverse people with mental health challenges. I received ethical approval for Site A approximately six months before I received ethical approval for Site B. Following ethical approval at Site A, I made initial contact with the leaders responsible for the mental health portfolio and explained the study over the phone. I was invited to attend a meeting with the 141  different managers of the various mental health programs within the organization and distributed written material about the study (Please see Appendix C “Letter of Introduction”). During this meeting, a key contact person was identified as a champion of the research to facilitate recruitment in the acute care program. The key contact made arrangements for me to attend the appropriate meetings to explain the study to staff, provide written information, and answer any questions. I also left written material at the site for staff not able to attend the meeting, and advertised for participants through site-specific media, and word of mouth. Several participants contacted me directly following these meetings to arrange an interview time. Other participants at Site A contacted me through word of mouth, requesting further information about the study, which I sent through email. If the participant expressed an interest in being interviewed, I followed up a maximum of two times to schedule an interview. At Site B, I had an internal partner who organized a meeting with the administrator and leadership team of the mental health program to explain the process and purpose of the study. I left written material about the study and contact information with the leadership team. Similar to the process at Site A, my internal partner facilitated recruitment of participants by making arrangements for me to attend the appropriate unit meetings to explain the process and purpose of the study. Written material about the study and contact information was left at these meetings for people who were unable to attend. The internal partner also advertised the study through site-specific media and word of mouth. When an individual contacted me for information about the study, I provided written 142  material through email and followed up a maximum of two times to arrange an interview. Data Sources Data collection occurred consecutively across two acute care mental health sites over 15 months. Glaser (1978) coined the phrase, “All is data” in GT. Information gathered from interviews, focus groups, field notes, memos, observations, and textual information, such as historical, agency documents, or government documents, can all be included as data (Charmaz, 2006). Data sources for this study included participant observation, field notes, individual interviews, organizational vision and values statements, and government documents. Participants In GT, a researcher gathers data through a variety of sources, including people who have an experience of the phenomenon under study. For this study, I recruited HCPs who self-identify as having experienced ethically challenging situations in the delivery of care in a mental health setting. There is a small body of research indicating that moral distress occurs at different levels of the system and not just with front-line care providers (Mitton et al., 2011). I attempted to recruit participants from across professional disciplines that provide direct care to patients, as well as from middle and upper management who have responsibility for policy development and enactment, including resource allocation related to 143  mental health care. However, I was unable to interview anyone in senior management who had responsibility for resource allocation. Description of participants. With the aid of a key informant at Site A and an internal partner at Site B, 27 participants from the disciplines of nursing, medicine, social work, and occupational therapy agreed to participate in the study. All 27 participants were interviewed, and three participants also agreed to being observed, resulting in 12 hours of data collection through observation. Most participants were reluctant to be observed, even though I had ethical approval, citing concerns about patient confidentiality and the expressed belief that they spend most of their time on the phone so I would have nothing to observe. The participants worked in acute care mental health, either providing direct care to patients, or functioning in a leadership position. Most, but not all, participants in a leadership position occupied positions with a union designation of direct care (DC) or Educational Activities (ED) 2 or 3, and were considered part of the Leadership Team for the Mental Health Program. All the participants on the leadership team were nurses. One of the physicians involved in this study also held a clinical leadership position. Table 1 below includes a summary of the information related to the participants.   144  Table 1 Participant Characteristics Total Number of Participants Designations Leadership Role Direct Care Average Age Gender Average Years in Position Average Years in HC 27 20 RPN/RN 2 MDs 2 OTs 3 SWs 13 (+1 physician) 14 (including physicians) 43.6 19 F 8 M 6.1 years Range 1 month – 23 years 35 years Range: 1 – 40 years Total Hours of Observation: 12 hours (3 participants) 3 RPN/RNS 1 Nurse in a leadership role 2 Nurses providing direct care      Data Collection Interviews. In-depth interviews are the most commonly used method for data collection in qualitative research (Charmaz, 2006; Nunkoosing, 2005; Thorne, 2008). Participant interviews took place at a time and location that was comfortable and convenient for the participant. The locations provided a certain level of privacy in order to maintain confidentiality of the participant and the information shared. Initial interviews were semistructured with open-ended questions based on my research questions. Almost all the interviews24 were digitally recorded, and lasted between 45-75 minutes. Immediately following the interview, I found a quiet place and wrote a memo about the process and the content of the interview in order to capture salient reflections that resulted from the interview. A transcriptionist transcribed completed interviews verbatim, and then I listened to the interview and reviewed the transcript for accuracy. The                                             24 Due to technical difficulties an interview was only partially recorded, while the recording for another interview was accidentally deleted from the digital recorder before it could be transcribed. 145  interview guide was adjusted as data were analyzed and core categories were developed (Please see Appendix D for the initial interview guide). Participant observation. Participant observation is a strategy that can be used to facilitate rich data collection and analysis (Charmaz, 2006). Participant observation as a data collection tool refers to the researcher who is more or less active in the observer role, through questions and conversation, and may become involved in some of the activities specific to the environment because examining human action is central to developing a grounded theory (Charmaz, 2006; Chenitz & Swanson, 1986; Thorne, 2008). I engaged in participant observation in both of the chosen sites in order to observe the processes involved in decision-making regarding, for example, resource allocation, staffing decisions, and decisions related to patient care, because examining human action is central to developing a grounded theory (Charmaz, 2006; Glaser & Strauss, 1967). Observation of these decision-making processes informed my developing theory about how HCPs enact their moral agency within the current health care context. For example, during one period of observation, I witnessed a participant balance the demands of actual practice, and the expectations of colleagues who focused on efficiency. This observation helped saturate the subcategory of living with bullying. To help gain entrance to the setting, and to build trust and credibility, I negotiated the level of my participation in unit activities with the unit manager prior to going on the unit. My participation was limited to activities that are supportive of staff, rather than direct patient care, for example, collecting supplies 146  for the participant (Thorne, 2008). Only a few participants agreed to being observed as they engaged in their job, and in these situations, participants only wanted me to accompany them for part of their shift. I engaged in four-hour observation periods with three participants. During the observation periods, I took field notes of the setting, the people present, and the process of the interactions among the people present in the setting. Immediately following the periods of observation, I wrote a memo to capture salient reflections. A critique of participant interviews in moral psychology research, is the dichotomy that can exist between declared beliefs and values that underpin action, and what people actually do in a given situation, particularly in research that focuses on moral action (Greene, 2003). This critique is especially relevant to research in moral decision-making, indicating that people make moral decisions based on intuition rather than rationality (Greene, 2003). Given this critique, I intended to combine interviews with participant observations to help enhance our current understanding of the interplay between structures and agents in the experience of moral distress. However, participants did not want to combine the interview with the observation time, so the observations took place on a shift and at a time that was convenient for the participant, after the interviews had been conducted. Participant observation was a valuable research method, but not without pitfalls. Bonner and Tolhurst (2002) have examined the advantages and disadvantages of participant observation from the perspectives of being an insider, from within the organization or discipline, and an outsider, from outside of 147  the organization. The authors identify advantages of being an insider related to already having established trust and intimate understanding of the group and group processes. Bonner and Tolhurst (2002) identify one of the primary disadvantages was the potential to overlook pertinent data due to familiarity with the participants and the setting. Both an advantage and a disadvantage to being an outsider was that the researcher is an unknown quantity to the participant or group (Bonner & Tolhurst, 2002). In this research, I was an outsider in all three periods of observation and did not have time to build up trust with those present in the environment, although several people were interested in what I was doing, and asked questions. Document review. Although I did not enter into this research with expectations about what I would find in the data, my previous work in moral distress, and familiarity with the literature did provide some indication regarding individual and structural issues that may contribute to the experience. Burston and Tuckett (2013) provide a summary of the literature and identified the factors that contributed to moral distress. As discussed in Chapter Two, these factors included lack of access to resources that support the provision of care, including adequate staffing, and time, issues that raise conflict between team members, and constraining health care regulation or organizational policy. Awareness of these issues alerted me to further sources of data that shed light on the relationship between structure and moral agency. Further sources of data I reviewed included 148   service plans for the Ministry of Health and Community Living British Columbia (CLBC);  provincial policy frameworks related to mental health, e.g. Improving Health Services for Individuals with Severe Addiction and Mental Illness (MoH, 2013);  provincial and national guidelines related to mental health and criminal justice, e.g. Secure Rooms and Seclusion Standards and Guidelines (MoH, 2012);  strategic planning documents for mental health care delivery at the Health Authorities (HA) or provincial level, e.g. MHSU Strategic and Operational Priorities, 2015-2020 (Fraser Health Authority, 2014); and  organizational and unit vision and values statements, when available. Data Analysis Data analysis began as soon as I completed the first interview and continued until I finished writing up my findings. I used the tenets of GT, originally advanced by Glaser and Strauss, as a means of theory development, including concurrent data collection, and data analysis, constant comparison, memoing, and theoretical saturation. Memoing. I used memoing to further develop conceptual categories and linkages between categories. Memoing is a flexible technique with the purpose of documenting ideas as they arise (Glaser, 1978; Schreiber, 2001b). The memoing process began before actual collection of data. I started writing memos early in the process to help identify what and how I might study moral distress. My 149  memos took different forms; for example some were written and at other times I recorded a voice memo. I also used mapping and drawing to try to work out relationships within the data, or as a means of visually clustering data (Charmaz, 2006; Schreiber, 2001b). Memo writing also served several purposes, including capturing ideas, making explicit, and reflecting on, assumptions, and tracking methodological decisions regarding the research (Schreiber, 2001).  Corbin and Strauss (1990) show that memos are not simply a way of keeping track of ideas; they are, in fact, related to the formulation of theory. I used memo writing to help form core categories and theoretical linkages that served as the foundation for theory. Throughout the process of analysis, I shared these memos with my supervisory committee members, who, in turn, helped me push my analysis further, and also clarify my thinking about the data. I continued to memo throughout the research, both to facilitate theory development and as a technique to foster reflexivity. I discuss reflexivity further in the discussion on rigor and evaluation of GT. Coding. Much has been written about the process of coding and the development of a grounded theory by moving codes to increasing levels of abstraction (Schreiber, 2001b). Glaser (1978) identifies two types of codes in GTM: substantive codes that conceptualize what is going on in the data, and theoretical codes that conceptualize how the substantive codes may relate to one another. He also describes a process of generating codes and moving substantive coding to theoretical coding. Charmaz (2014) shows that coding includes at least two main phases, the first being an initial coding that involves 150  assigning a name or code to a word, line, or segment of data. This is followed by a more focused selective phase to help organize, sort, and synthesize large amounts of data. Although it appears that coding moves in a linear fashion from simple to more abstract, coding is an iterative process and coding at different levels of abstraction can occur simultaneously (Charmaz, 2006; Glaser, 1978; Schreiber, 2001b). I began data analysis with line-by-line coding, a process by which I read through, and coded each line or phrase of data, linking these small units of data to a conceptual code (Glaser, 1978; Schreiber, 2001b). In this first phase of coding, I chose codes or words that closely followed the data. I used gerunds, or words ending in ing, as much as possible to help bring action and processes to the forefront (Charmaz, 2006; 2011). Fracturing the data and applying conceptual codes helped me recognize similarities and differences occurring in the data (Glaser, 1978; Schreiber, 2001b). For the first stage of data analysis, I created a code book in an Excel spreadsheet to keep track of the line-by-line codes. I conducted line-by-line coding on the first four interviews, resulting in 225 initial codes. As first level codes increased and I began to cluster similar codes together, I moved to writing the codes on 3 x 5 flash cards so I could make notes about the codes on the back of the cards, and I could maintain flexibility in creating focused codes. As I collapsed conceptual codes into focused codes, I compared them against incoming data. In creating focused codes that subsume lower level concepts, or second level coding (Schreiber, 2001b), I began to move the