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Developing countries, Ethnography, Global health, India, Low- and middle-income countries, Moral distress, Morphine, Nurses, Oncology, Opioids, Palliative care



  1. LeBaron, Virginia PhD, APRN
  2. Beck, Susan L. PhD, APRN
  3. Black, Fraser MD
  4. Palat, Gayatri MBBS


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.


Implications for Practice: 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.