title: Nurse moral distress and cancer pain management: an ethnography of oncology nurses in India.
abstract: BACKGROUND
  The majority of cancer patients in low- and middle-income countries (LMICs) present with late-stage, incurable disease, and basic tools to alleviate patient suffering-such as morphine-are often absent. Oncology nurses must cope with many challenges and may experience moral distress (MD), yet little research has examined this experience in LMICs.
  
  
  OBJECTIVE
  This ethnographic study explored the experience of MD with oncology nurses (n = 37) and other providers (n = 22) in India and its potential relationship to opioid availability.
  
  
  METHODS
  Data (semistructured interviews and field observations) were collected at a 300-bed government cancer hospital in urban South India over 9 months. Dedoose v.4.5.91 supported analysis of transcripts using a coding schema that mapped to an Integrated Model of Nurse Moral Distress and concepts that emerged from field notes.
  
  
  RESULTS
  Primary themes included "We feel bad," "We are alone and afraid," "We are helpless," and "We leave it." A weak link between MD and opioid availability was found.
  
  
  CONCLUSIONS
  Participants described significant work-related distress, but the moral dimension to this distress was less clear as some key aspects of the Integrated Model of Nurse Moral Distress were not supported. The concept of MD may have limited applicability in settings where alternative courses of action are unknown, or not feasible, and where differing social and cultural norms influence moral sensitivity.
  
  
  CONCLUSIONS
  Improving job-related conditions is prerequisite to creating an environment where MD can manifest. Educational initiatives in LMICs must account for the role of the oncology nurse and their contextual moral and professional obligations.
authors.affiliation: Author Affiliations: Dana-Farber Cancer Institute, University of Massachusetts, Boston (Dr LeBaron); College of Nursing, University of Utah, Salt Lake City (Dr Beck); Victoria Hospice, British Columbia, Canada (Dr Black); and the International Network for Cancer Treatment and Research, India (Dr Palat).
authors.forename: Virginia
authors.initials: V
authors.lastname: LeBaron
authors.forename: Susan L
authors.initials: SL
authors.lastname: Beck
authors.forename: Fraser
authors.initials: F
authors.lastname: Black
authors.forename: Gayatri
authors.initials: G
authors.lastname: Palat
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000884:Anthropology, Cultural; D005260:Female; D006801:Humans; D007194:India / Q000208:ethnology; D008297:Male; D008875:Middle Aged; D009014:Morals; D009369:Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000451:nursing; D009726:Nurses / Q000523:psychology*; D059408:Pain Management / Q000379:methods / Q000451:nursing / Q000523:psychology*; D013315:Stress, Psychological / Q000209:etiology* / Q000523:psychology
chemical_list: D000701:Analgesics, Opioid