ESRQ-MORAL STRESS The phenomenon of moral stress is probably as old as mankind. The problems of fulfilling the

7.1 ESRQ-MORAL STRESS The phenomenon of moral stress is probably as old as mankind. The problems of fulfilling the

intentions of good will, doing the rights things and acting accordingly has been convincingly formulated by Saint Paul:

For I do not do the good I want, but the evil I do not want is what I do. (Rom 7:19 Revised Standard Version)

Scholarships

Open your mind to new opportunities

With 31,000 students, Linnaeus University is one of the larger universities in Sweden. We are a modern university, known for our strong international profile. Every year more than

Bachelor programmes in

1,600 international students from all over the Business & Economics | Computer Science/IT | world choose to enjoy the friendly atmosphere

Design | Mathematics

and active student life at Linnaeus University. Welcome to join us! Master programmes in

Business & Economics | Behavioural Sciences | Computer Science/IT | Cultural Studies & Social Sciences | Design | Mathematics | Natural Sciences | Technology & Engineering

Summer Academy courses

Recently, Nilsson et al. (2011) explored the issue of moral stress in connection with international humanitarian aid and rescue operations. This particular investigation was a qualitative interview study using a grounded theory methodology. The study resulted in a theoretical model, which in a slightly simplified form is presented in Figure 4.

Disaster/Humanitarian crisis situation Katastrof/Humanitä

Aid or rescue operation

Contextual conditions affecting the operation

- Formalities: the “objective/hard” reality - Culture: the “subjective/soft” reality - - Safety - Media

Interpretation of contextual conditions Tolkning av kontextuella f örhållanden

Obstacle to completion of task Hinder för upp- Anpassade till Adapted to completion ösande

of task ösande

No moral stress

Decision making strategy Beslutstrategi

- Common sense guides the initial coping - Sunt f örnuft - Söka chefers godkännande och stöd - Seek leader sanction and support

Brist p å chefers Mistrust and lack of Trust and leader Chefers god- godkännande och stöd leader support

kännande och stöd support

No moral stress

Deliberations Överväganden

- Aktivt val att agera i enlighet med, eller i kontrast till, vad som förväntas givet - Active choice to act in accordance with, or contrary to, what is expected given the current contextual conditions rådande kontextuella förhållanden - Vara medveten om risker, speciellt d å man agerar i kontrast till vad som f örväntas - Be aware of risks, particularly when acting against what is expected - Återvända till det som f örväntas s å fort som m öjligt - Return as soon as possible to what is expected

Task outcome of chosen act Uppgiftens utfall utifr ån vald handling

- OK when successful - OK vid framgång - Personally accountable when successfull/not succesfull - Personligt ansvarig vid framgång/nederlag

Ej framgångsrik Not successful Framgångsrik Successful

No moral stress

Moral stress reaction Moralisk stress reaktion

- Otillräcklighet - Maktlöshet - Insufficiency - Meningslöshet - Powerlessness - Frustration - Meaninglessness

- Frustration

Figure 4. Ethical decision making from a moral stress perspective during acute situations (adapted from Nilsson et al. 2011).

The model illustrates a process that, under certain conditions, may lead to moral stress, shown in ideal typical form elf, such as a disaster or other kind of humanitarian crisis situation. This, of course, is a necessary condition for an aid or a rescue operation and is not further elaborated here.

A number of contextual conditions such as formalities, culture, safety aspects and the media affect the aid or rescue operation. The typical humanitarian assistance professional interprets the meaning of these conditions and the appraisal processes results in a position on a continuum ranging from understanding the situation as compatible with one’s inner moral guidelines to evaluating it as having obstacles in these respects. In the first case, there will be no moral stress. When the situation is interpreted as problematic, a morally challenging decision-making process begins. A core initial aspect of this is to seek mandate and support from one’s superior. If this received, there will be no moral stress according to this ideal typical model. On the other hand, if such support is not received, the humanitarian assistance professional must make an active choice, be aware of the risks of acting contrary to what is expected given the current contextual conditions.

The next step in the model is task outcome, when the humanitarian assistance professional has acted in accordance with his or her inner moral conviction but contrary to what the contextual conditions suggest. If the outcome is successful, one may avoid moral stress, but this is not self-evident, and in these cases one may suffer from negative stress reactions. When one’s choice of action results in a task outcome that is not successful, a stress reaction occurs that can be labeled as moral stress. This is characterized by experiences of insufficiency, powerlessness, meaninglessness, and frustration (Nilsson et al. 2011).

When discussing the findings, we turned to the theoretical framework of Lazarus and wrote the following (Nilsson et al. 2011):

“Four kinds of experiences were brought forward by the informants: insufficiency, powerlessness, meaninglessness, and frustration. According to Lazarus (1991), meaninglessness and frustration (and also helplessness) are regarded as “ambiguous negative states” (p. 83) rather than as emotions. These states are involved in emotions as a preceding appraisal, but they are not emotions themselves. Rather they describe the evaluation of a given person- environment relationship (Lazarus 1991). We suggest that this holds true for insufficiency and powerlessness as well. In further support of this notion, none of the negative states we have identified can be found in the Shaver et al. (1987) extensive cluster analysis of 135 emotion names.” (p. 66)

7.1.1 MEASUREMENT OF MORAL STRESS Based on the above-mentioned study by Nilsson et al. (2011), a special version of the

ESRQ was developed, simply composed by adding the four moral stress reaction words, insufficiency, powerlessness, meaninglessness, and frustration to the original 14 ESRQ words. The standard ESRQ response scale is used. Results interpretations may be based on each of the four word separately, or on a sum score. Examples of empirical results where the aggregate moral stress reaction score have been used are presented in Chapter 8.