title: Moral distress among Ugandan nurses providing HIV care: a critical ethnography.
abstract: BACKGROUND
  The phenomenon of moral distress among nurses has been described in a variety of high-income countries and practice settings. Defined as the biopsychosocial, cognitive, and behavioural effects experienced by clinicians when their values are compromised by internal or external constraints, it results from the inability to provide the desired care to patients. No research has been reported that addresses moral distress in severely resource-challenged regions such as sub-Saharan Africa.
  
  
  OBJECTIVE
  To describe the manifestation and impact of moral distress as it was experienced by Ugandan nurses who provided care to HIV-infected or -affected people.
  
  
  METHODS
  A critical ethnography was conducted with 24 acute care and public health nurses at a large referral centre in Uganda. Data were collected through interviews, observation, and focus group discussions.
  
  
  RESULTS
  Participants described their passion for nursing and commitment to patients. They experienced moral distress when a lack of resources put patients' wellbeing at risk. The trauma imposed by systemic challenges on the nursing profession was acknowledged, as was the perception that the public blamed nurses for poor patient outcomes. However, participants were determined to serve to the best of their abilities and to take satisfaction from any contributions they were able to make. They cited the importance of education in the development of their capacity to provide care with a positive attitude, and demonstrated a collective resilience as they discussed strategies for addressing issues that affected them and their colleagues.
  
  
  CONCLUSIONS
  The experience of moral distress among nurses in Uganda differed somewhat from the experience of nurses in high-income countries. Constraints imposed by the inability to implement skills and knowledge to their fullest extent, as well as a lack of resources and infrastructure may result in the omission of care for patients. Moral distress appears to manifest within a relational and contextual environment and participants focussed on the impact for patients, communities, and the nursing profession as a whole, rather than on their own personal suffering. The opportunity for continuing education led to strategies to transform personal attitudes and practice as well as to enhance the presentation of the profession to the public.
authors.affiliation: Faculty of Health Sciences, University of Lethbridge, 4401 University Drive West, Lethbridge, Alberta, Canada. harrjn@uleth.ca
authors.forename: Jean N
authors.initials: JN
authors.lastname: Harrowing
authors.forename: Judy
authors.initials: J
authors.lastname: Mill
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000884:Anthropology, Cultural; D001291:Attitude of Health Personnel; D002055:Burnout, Professional / Q000523:psychology*; D003906:Developing Countries; D004509:Education, Nursing, Continuing / Q000458:organization & administration*; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000451:nursing*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008875:Middle Aged; D009014:Morals; D015402:Nursing Education Research; D015404:Nursing Methodology Research; D009740:Nursing Staff / Q000193:education / Q000941:ethics / Q000523:psychology; D010344:Patient Advocacy / Q000193:education / Q000941:ethics / Q000523:psychology; D015397:Program Evaluation; D036301:Qualitative Research; D011795:Surveys and Questionnaires; D014454:Uganda