Framing the issues: moral distress in health care

Burnout and moral resilience in interdisciplinary healthcare professionals

AIMS AND OBJECTIVES

To examine demographic and work characteristics of interdisciplinary healthcare professionals associated with higher burnout and to examine whether the four domains of moral resilience contribute to burnout over and above work and demographic variables.

BACKGROUND

Healthcare professionals experience complex ethical challenges on a daily basis leading to burnout and moral distress. Measurement of moral resilience is a new and vital step in creating tailored interventions that will foster moral resilience at the bedside.

DESIGN

Cross-sectional descriptive design.

METHODS

Healthcare professionals in the eastern USA were recruited weekly via email for 3 weeks in this cross-sectional study. Online questionnaires were used to conduct the study. The STROBE checklist was used to report the results.

RESULTS

Work and demographic factors, such as religious preference, years worked in a healthcare profession, practice location, race, patient age, profession and education level, have unique relationships with burnout subscales and turnover intention, with the four subscales of moral resilience demonstrating a protective relationship with outcomes above and beyond the variance explained by work and demographic characteristics.

CONCLUSIONS

Higher moral resilience is related to lower burnout and turnover intentions, with multiple work demographic correlates allowing for potential areas of intervention to deal with an increase in morally distressing situations occurring at the bedside. Additionally, patterns of significant and non-significant relationships between the moral resilience subscales and burnout subscales indicate that these subscales represent unique constructs.

RELEVANCE TO CLINICAL PRACTICE

Understanding the everyday, pre-pandemic correlations of moral resilience and burnout among interdisciplinary clinicians allows us to see changes that may exist. Measuring and understanding moral resilience in healthcare professionals is vital for creating ways to build healthier, more sustainable clinical work environments and enhanced patient care delivery.

Moral distress in nurses caring for patients with Covid-19

BACKGROUND

Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic.

OBJECTIVE

To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency.

RESEARCH DESIGN

A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020.

ETHICAL CONSIDERATIONS

We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore.

RESULTS

We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies.

DISCUSSION/CONCLUSION

Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses' moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences.

Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals

OBJECTIVES

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP).

METHODS

We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted.

RESULTS

308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument.

CONCLUSIONS

The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.

Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

Loneliness Among Older Home-Dwelling Persons: A Challenge for Home Care Nurses

Aim

To explore how nurses working in the home care service sector perceived the loneliness experienced by older people living at home, and how they met these lonely individuals’ needs.

Background

Loneliness is a well-known phenomenon among groups of older home-dwelling people and has been shown to be a health-related problem. Health care professionals working in the primary care sector, such as home care nurses, may be in the position to identify loneliness among at-home seniors. Identifying and addressing loneliness must become important issues in home care nursing.

Design

A qualitative study.

Methods

Focus group interviews were performed with 11 home care nurses in Norway. The interviews were analyzed in accordance with manifest and latent content analysis. The Coreq checklist was followed.

Findings

Home care nurses identified loneliness among older people as being a complex and sensitive phenomenon that activated conflicted thoughts, feelings and solutions in a system where older people’s loneliness was generally not considered as a need requiring nursing care.

Conclusion

Loneliness among older people challenged the nurses with regard to communicating older people’s feelings of loneliness and meeting their social needs. Organizational structures were perceived as being the main barriers to meeting these needs. Older people’s feelings of loneliness stimulated nurses’ reflections about the purpose of their nursing role. It is important to address loneliness among older home-dwelling people and include the issue in home care nursing in order to meet their need for social contact. Home nursing leaders must pay attention to the nurses’ experiences, promote the nurses’ acquisition of knowledge about this kind of loneliness and learn how to meet an older individual’s needs. There should be a special focus on communicating with lonely older people in order to address their feelings loneliness.

Working in the Times of COVID-19. Psychological Impact of the Pandemic in Frontline Workers in Spain

This study evaluates the psychological impact (PI) of the COVID-19 pandemic in frontline workers in Spain. Participants were 546 workers (296 healthcare workers, 105 media professionals, 89 grocery workers, and 83 protective service workers). They all completed online questionnaires assessing PI, sadness, concerns related to the COVID-19 pandemic, and demographic and work-related variables. All groups but protective services workers showed higher PI levels than the general population. Healthcare and grocery workers were the most affected, with 73.6% and 65.2% of the participants, respectively, showing a severe PI. Women showed a higher PI level. Healthcare workers in the regions with higher COVID-19 incidences reported greater PI levels. The main concerns were being infected by COVID-19 or infecting others. Levels of concern correlated with higher PI levels. The protection equipment was generally reported as insufficient, which correlated with higher PI levels. Professionals reporting to overwork during the crisis (60% mass-media, 38% of healthcare and grocery and 21.7% of protective service) showed higher PI levels. In the healthcare group, taking care of patients with COVID-19 (77%) or of dying patients with COVID-19 (43.9%) was associated with higher PI levels. The perceived social recognition of their work was inversely related to PI. Most of the sample had not received psychological support. We suggest some organizational measures for frontline institutions, such as the periodical monitoring or inclusion of psychologists specialized in crisis-management to prevent negative symptoms and provide timely support.

Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout

OBJECTIVE

Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout.

METHODS

Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory.

RESULTS

Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9-7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7-23.5) than hospitalists. The most frequent source of moral distress was "having excessive documentation requirements that compromise patient care," and the most intense source of moral distress was "be[ing] required to work with abusive patients/family members who are compromising quality of care." Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5-41.2).

CONCLUSIONS

Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.

Referral Prioritization in Home Care Occupational Therapy: A Matter of Perspective

Background.

Prioritizing referrals for home care occupational therapy is somewhat subjective, and public and patient perspectives on waiting list priorities are unknown.

Purpose.

To explore the views of home care occupational therapists (OTs), older persons (OPs) and adults with disabilities on waiting list priorities, as well as issues and challenges underlying these priorities.

Method.

We conducted in-depth interviews with 11 OTs, 10 OPs and 9 adults with disabilities. Participants were asked to prioritize referral scenarios while explaining their choices. Directed and conventional content analysis allowed the identification of themes for each group of participants.

Findings.

OTs experienced conflicts of values but mainly prioritized referrals based on client safety. OPs sought to maximize client’s independence, and persons with disabilities aimed to improve clients’ social participation.

Implications.

OTs should seek the perspectives of their target clientele on referral prioritization criteria and strive to adjust prioritization practices accordingly.

Moral distress: A concept clarification

Background

Over the past few decades, moral distress has been examined in the nursing literature. It is thought to occur when an individual has made a moral decision but is unable to act on it, often attributable to constraints, internal or external. Varying definitions can be found throughout the healthcare literature. This lack of cohesion has led to complications for study of the phenomenon, along with its effects to nursing practice, education and targeted policy development.

Objectives

The aim of this analysis was to uncover unique definitions of moral distress as found in the nursing literature and to examine the relationship between these definitions.

Research Design and Context

Morse’s method of concept clarification was applied given the large body of literature which includes definitions, descriptions and measurements of the concept in research. The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing, and contrasting attributes, antecedents and consequences of each category.

Findings

Each of the 18 included studies described constraints in their definition of moral distress, whether implied or explicitly stated. External constraints are widely described as obstacles outside of the individual, whether institutional, systemic or situational, while internal constraints are located within the individuals themselves and are described as personal limitations, failings or weakness of will.

Conclusion

Upon reviewing these definitions, we determined that the term ‘internal constraints’ is problematic due to the emphasis of responsibility on the individual experiencing moral distress. We propose an alteration to ‘internal characteristics’ that will assume less responsibility of change from the individual to place a heavier onus on systemic and institutional constraints.

Association between ethical leadership, ethical climate and organizational citizenship behavior from nurses' perspective: a descriptive correlational study

Background

Ethical leadership plays an important role in improving the organizational climate and may be have an effect on citizenship behavior. Despite the growing emphasis on ethics in organizations, little attention to has been given this issue. The purpose of this study was to identify ethical leadership, an ethical climate, and their relationship with organizational citizenship behavior from nurses’ perspective.

Methods

In this descriptive correlational study, 250 nurses in twelve teaching hospitals in Tehran were selected by multistage sampling during 2016–2017. The data were collected using Ethical Leadership Questionnaire, Hospital Ethical Climate Survey, and Organizational Citizenship Behavior Scale.

Results

The findings showed a significant correlation between ethical leadership in managers, organizational citizenship behavior (P = 0.04, r = 0.09) and an ethical climate (P < 0.001, r = 0.65). There was a significant correlation between an ethical climate and nurses’ organizational citizenship behavior (P < 0.001, r = 0.61). The regression analysis showed that ethical leadership and an ethical climate is a predictor of organizational citizenship behavior and confirms the relationship between the variables.

Conclusion

Applying an ethical leadership style and creating the necessary conditions for a proper ethical climate in hospitals lead to increased organizational citizenship behavior by staff. To achieve organizational goals, nurse managers can use these concepts to enhance nurses’ satisfaction and improve their performance.

Moral distress revisited: the viewpoints and responses of nurses

AIM

To present and discuss the main themes that were revealed following an analysis of the qualitative research findings that were extracted from a national survey regarding the causes and effects of moral distress amongst New Zealand nurses.

BACKGROUND/INTRODUCTION

Moral distress continues to be a major concern amongst nurses around the world. In New Zealand, a country where nurses have just been on strike over their working conditions and the deteriorating state of their roles within the health services, it remains a major issue.

METHOD

In the original research project, large numbers of nurses supplied not only quantitative data that revealed the extent and impact of moral distress on their practices, but also extensive notes that more specifically explained the causes and effects of their moral distress. This material has since been thematically analysed and is now presented.

FINDINGS/RESULTS

The data strongly suggested that New Zealand nurses experienced and attempted to respond to several major issues; that is, they were not properly supported by 'the system', frequently experienced problems with managers and bullying, witnessing poor care practices and collegial incompetence, and suffered from ongoing problems caused by moral residue.

CONCLUSION

Under current working conditions, nurses are struggling under an increasing weight of moral residue to maintain their ethical standards within an increasingly difficult ethical climate.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This research suggests that although nurses clearly seek out and use various ways to cope with moral distress in their practices, there is a continuing need for moral courage and strengthening of moral resilience that involves greater input from not just nurses themselves, but nurse managers, educators and other health services representatives.

Moral distress in the critical care air transport nurse

BACKGROUND

Moral distress in healthcare providers occurs when the perceived right action cannot or is not taken and results in a loss of moral integrity. Critical Care Air Transport (CCAT) nurses are elite U.S. Air Force (USAF) clinicians who provide healthcare during transport of injured military members. CCAT nurses are vulnerable to physical and psychological stressors, including fatigue, multiple traumas, limited resources and ethical dilemmas.

PURPOSE

The purpose of this study was to explore moral distress in USAF CCAT nurses.

METHODS

Using interpretative hermeneutic phenomenology, we described the lived experience of moral distress in 15 CCAT nurses.

FINDINGS

Seven themes emerged to describe the CCAT nurses experiences of moral distress. These include: Not Prepared, Agent of Healing or Agent of Harm, Live or Let Die, Robbing Peter to Pay Paul, Ever Decreasing Circles, Cultural Dissonance, and Incongruence with Colleagues.

DISCUSSION

This study highlighted both similarities and differences in moral distress than those described previously in the literature. Military unique situations contribute to the experience of moral distress in USAF CCAT nurses. These findings will guide future research aimed at understanding and mitigating moral distress effects in military nurses and other healthcare providers.

Situating moral distress within relational ethics

Nurses may, and often do, experience moral distress in their careers. This is related to the complicated work environment and the complex nature of ethical situations in everyday nursing practice. The outcomes of moral distress may include psychological and physical symptoms, reduced job satisfaction and even inadequate or inappropriate nursing care. Moral distress can also impact retention of nurses. Although research has grown considerably over the past few decades, there is still a great deal about this topic that we do not know including how to deal well with moral distress. A critical key step is to develop a deeper understanding of relational practice as it pertains to moral distress. In this article, exploration of the experience of moral distress among nurses is guided by the key elements of relational ethics. This ethical approach was chosen because it recognizes that ethical practice is situated in relationships and it acknowledges the importance of the broader environment on influencing ethical action. The findings from this theoretical exploration will provide a theoretical foundation upon which to advance our knowledge about moral distress.

Ethical Awareness Scale: Replication Testing, Invariance Analysis, and Implications

Background: Ethical awareness (EA) enables nurses to recognize the ethical implications of all practice actions and is an important component of safe and quality nursing care. Evidence suggests that nurses may sometimes feel underprepared to recognize and address ethical issues as they arise in practice. The Ethical Awareness Scale (EAS) presented strong evidence as a psychometrically sound measure of EA in critical care nurses in pilot testing. The present study extends earlier work by (a) expanding the sample, (b) replicating the psychometric analyses, (c) more deeply investigating data-to-model fit, and (d) providing guidelines for the interpretation of EAS scores and subsequent practice-focused and educational interventions. Methods: This study utilized two sets of cross-sectional EAS survey results with ICU nurse respondents from two hospitals in New England. Invariance testing using simple OLS regression was conducted between the item estimates of both samples. The final Rasch analysis utilized a rating scale model. Finally, a score interpretation framework was developed. Results: 240 participants were included in the combined analysis. Nurses were predominantly female (93.1%), aged 25-35 (39.9%), and Bachelor's degree prepared (73.4%). Mean levels of EA were in the low/moderate range (M = 36.2/54). Cronbach's alpha of 0.86 was achieved. The Rasch analysis demonstrated a variable map structure consistent with the hypothesized item order, scoring categories that were sufficiently used by respondents, and adequate model-data fit. Conclusions: This study demonstrates that the EAS is a psychometrically sound and meaningful measure of EA in critical care nurses with item difficulty estimates that are invariant across samples. A raw score on the EAS can be practically interpreted, given the theoretical description of what a nurse at each level of the scale's continuum may "look" like in terms of EA using the diagnostic interpretation table. These findings have implications for nursing education and practice.

Removal of babies at birth and the moral distress of midwives

BACKGROUND

Midwives and nurses appear vulnerable to moral distress when caring for women whose babies are removed at birth. They may experience professional dissatisfaction and their relationships with women, families and colleagues may be compromised. The impact of moral distress may manifest as anger, guilt, frustration, anxiety and a desire to give up their profession. While there has been much attention exploring the concept of moral distress in midwifery, this is the first study to explore its association in this context.

AIM

This article explores midwives' experiences of moral distress when providing care to women whose babies were removed at birth and gives valuable insight into an issue nurses and midwives encounter in their profession.

METHODS

Four mothers and eight midwives took part in this research. Narrative inquiry incorporating photo-elicitation techniques was used to generate data; mothers were interviewed face to face and midwives through focus groups. The images and audio data were collected, transcribed and analysed for emerging themes. For the purpose of this article, only the midwives' stories are reported. This research received a favourable ethical opinion from the University of Surrey Ethics committee.

ETHICAL CONSIDERATIONS

This study received a favourable ethical approval from a higher education institutes ethics committee.

RESULTS

Midwives who care for women whose babies are removed at birth report it as one of the most distressing areas of contemporary clinical practice. Furthermore, they report feelings of guilt, helplessness and betrayal of the midwife-mother relationship. Many of the midwives in this study state that these experiences stay with them for a long time, far more than more joyful aspects of their role.

CONCLUSION

Midwives experience moral distress. Support systems, education and training must be available to them if we are to reduce the long-term impact upon them, alleviate their distress and prevent them from leaving the profession.

Ethical leadership, nursing error and error reporting from the nurses’ perspective

Background:

Nursing errors endanger patient safety, and error reporting helps identify errors and system vulnerabilities. Nursing managers play a key role in preventing nursing errors by using leadership skills. One of the leadership approaches is ethical leadership.

Aim:

This study determined the level of ethical leadership from the nurses’ perspective and its effect on nursing error and error reporting in teaching hospitals affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Research design:

This was a cross-sectional descriptive study.

Participants and research context:

A total of 171 nurses working in medical-surgical wards were selected through random sampling. Data collection was carried out using “ethical leadership in nursing, nursing errors and error reporting” questionnaires. Data were analyzed with SPSS20 using descriptive and analytical statistics.

Ethical considerations:

This study was approved by the Ethics Committee for Medical Research. Ethical considerations such as completing informed consent form, ensuring confidentiality of information, explaining research objectives, and voluntary participation were observed in the present study.

Findings:

The results showed that the level of nursing managers’ ethical leadership was moderate from the nurses’ point of view. The highest and the lowest levels were related to the power-sharing and task-oriented dimensions, respectively. There was a significant relationship between nursing managers’ level of ethical leadership with error rates and error reporting.

Conclusion:

The development of ethical leadership approach in nursing managers reduces error rate and increases error reporting. Programs designed to promote such approach in nursing managers at all levels can help reduce the level of error rate and maintain patient safety.

The Effect of Demographic and Social Factors on the Decision-Making of Community Pharmacists in Ethical Dilemmas

OBJECTIVE

The objective of the study is to investigate the effect of demographic and social factors on the decision-making of community pharmacists when confronted with ethical dilemmas during their professional practice.

METHODS

This was a questionnaire-based, cross-sectional study. A total of 1057 community pharmacists were approached. The final participants were 742. Independent-sample t-test and one-way analysis of variance were used to analyze the factors (age, gender, work experience, education qualification, number of pharmacists per pharmacy, and pharmacy location).

FINDINGS

Older pharmacists, experienced pharmacists, and urban pharmacists have less ethical dilemma compared to the younger pharmacists, less work experience pharmacists, and rural pharmacists, respectively.

CONCLUSION

Individual factors such as age, gender, work experience, and educational level and organizational factors such as the number of pharmacists in a pharmacy and location of pharmacy may influence the ethical dilemma of community pharmacists.

Clinician, student and faculty perspectives on the audiology-industry interface: implications for ethics education

Objective: Supporting audiologists to work ethically with industry requires theory-building research. This study sought to answer: How do audiologists view their relationship with industry in terms of ethical implications? What do audiologists do when faced with ethical tensions? How do social and systemic structures influence these views and actions? Design: A constructivist grounded theory study was conducted using semi-structured interviews of clinicians, students and faculty. Study sample: A purposive sample of 19 Canadian and American audiologists was recruited with representation across clinical, academic, educational and industry work settings. Theoretical sampling of grey literature occurred alongside audiologist sampling. Interpretations were informed by the concepts of ethical tensions as ethical uncertainty, dilemmas and distress. Results: Findings identified the audiology-industry relationship as symbiotic but not wholly positive. A range of responses included denying ethical tensions to avoiding any industry interactions altogether. Several of our participants who had experienced ethical distress quit their jobs to resolve the distress. Systemic influences included the economy, professional autonomy and the hidden curriculum. Conclusions: In direct response to our findings, the authors suggest a move to include virtues-based practice, an explicit curriculum for learning ethical industry relations, theoretically-aligned ethics education approaches and systemic and structural change.

Tensions Living Out Professional Values for Physical Therapists Treating Injured Workers

Health care services provided by workers' compensation systems aim to facilitate recovery for injured workers. However, some features of these systems pose barriers to high quality care and challenge health care professionals in their everyday work. We used interpretive description methodology to explore ethical tensions experienced by physical therapists caring for patients with musculoskeletal injuries compensated by Workers' Compensation Boards. We conducted in-depth interviews with 40 physical therapists and leaders in the physical therapy and workers' compensation fields from three Canadian provinces and analyzed transcripts using concurrent and constant comparative techniques. Through our analysis, we developed inductive themes reflecting significant challenges experienced by participants in upholding three core professional values: equity, competence, and autonomy. These challenges illustrate multiple facets of physical therapists' struggles to uphold moral commitments and preserve their sense of professional integrity while providing care to injured workers within a complex health service system.

What is 'moral distress'? A narrative synthesis of the literature

AIMS

The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.

BACKGROUND

Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.

DESIGN

Systematic literature review and narrative synthesis (November 2015-March 2016).

DATA SOURCES

Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946-Present, PsycINFO® 1967-Present, CINAHL® Plus 1937-Present, EMBASE 1974-24 February 2016, British Nursing Index 1994-Present, Social Care Online, Social Policy and Practice Database (1890-Present), ERIC (EBSCO) 1966-Present and Education Abstracts.

REVIEW METHODS

Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.

RESULTS

In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.

CONCLUSION

We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.

Phronesis of nurses: A response to moral distress

Background:

As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action.

Aim:

To describe and analyze the phronesis applied by nurses in the face of moral distress.

Research design:

The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses’ phronesis.

Participants:

Twenty-seven nurses from Taiwan.

Ethical considerations:

The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review.

Findings:

According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse’s emotional movement. Action and idea transformation are collectively called phronesis in this study.

Discussion:

Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress.

Conclusion:

Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Moral reasoning explained by personality traits and moral disengagement: A study among Dutch nurse practitioners and physician assistants

AIM

To explore the direct and indirect effect of the personality meta-traits 'Stability' and 'Plasticity' on moral reasoning among nurse practitioners (NPs) and physician assistants (PAs).

BACKGROUND

Moral reasoning is influenced by being prone to moral disengagement and personality traits. Moral disengagement is observed among professionals in many fields, including healthcare providers. Moral disengagement is known to be provoked by environmental stressors and influenced by certain personality traits.

DESIGN

A cross-sectional approach was used including self-report questionnaires.

METHODS

A convenience sample of Dutch NPs (N = 67) and PAs (N = 88) was surveyed via online questionnaires between January and March 2015, using (a) the Defining Issues Test; (b) the BIG five inventory; and (c) the Moral Disengagement Scale. Structural equation modelling (SEM) was employed for estimating the construct validity of two meta-traits of personality and to test unidirectional influences on moral reasoning.

RESULTS

Only the Stability trait was a direct predictor of moral reasoning whereas both Stability and Plasticity were precursors of moral disengagement. Both personality meta-traits had statistically significant indirect effects on moral reasoning through a low level of moral disengagement. The influence of both personality traits on the level of moral reasoning was increased by strong self-censure on entering into morally disengaged interactions.

CONCLUSION

The personality meta-trait 'Stability' is an indicator of moral reasoning and is explained by a lower propensity to morally disengage among highly stable people. Although the meta-trait Plasticity exerts an indirect effect through moral disengagement on moral reasoning, it is not a direct indicator of moral reasoning.

Moral Distress and Resilience in the Occupational Therapy Workplace

Healthcare professionals are inherently vulnerable to moral distress due to their frequent work with persons who are suffering or in crisis, in combination with the strong empathic orientation that underpins the very act of care giving. When accompanied by high workloads, deficiencies in management practices such as low recognition, lack of work autonomy, and/or insufficient opportunity for growth and development, persons in caring professions are at an even higher risk of moral distress. There is evidence that professional resilience is effective in mitigating workplace stress. Successful individual-management of moral distress requires attention to the broader institutional conditions under which these difficulties arise. This paper presents findings from 79 occupational therapists in Alberta and Saskatchewan, Canada, who participated in a survey of moral distress and resilience. On a standardized measure of resiliency their scores fell at the lower end of normal. On a standardized measure of moral distress, the highest levels involved issues of: time to do the job properly, deteriorated quality of care, insensitive co-workers, and unrealistic expectations from others. Nearly 50% reported that they had considered leaving a position due to moral distress. The survey was carried out with the goal of developing a teaching module that included education about moral distress and recommendations for the enhancement of both individual resilience and the construction of resiliency-promoting work environments.

Evaluation of a paediatric clinical ethics service

AIM

To evaluate a paediatric clinical ethics service incorporating both normative and empirical analysis.

METHODS

Section 1: Review of consensus guidelines to identify emerging standards for clinical ethics services (CES) and evaluation of the service in relation to these. Section 2: Description of service activity data. Section 3: Feedback from clinical staff involved in clinical ethics consultations was collected using a web-based survey.

RESULTS

Four guideline documents were reviewed, and clear emerging consensus standards were identified. Our service fulfils identified knowledge and skill core competencies and at least partially fulfils all of the identified service-level standards. Clinicians report that clinical ethics consultation decreases their moral distress.

CONCLUSIONS

There is emerging consensus for staff competencies and service-level standards for CES. The role of CES in staff well-being needs to be explored. Collaborative, multi-modal research to develop standards and evaluate CES is needed.

Moral dilemmas reflect professional core values of pharmacists in community pharmacy

Objectives

The aim was to recognise the professional core values in the moral dilemmas of pharmacists in community pharmacy and to customise the descriptions of these values for community pharmacy practice.

Methods

The narratives of 128 moral dilemmas, collected from Dutch PharmD students and early career pharmacists who experienced these dilemmas in practice, were qualitatively analysed. An expert panel deductively coded relevant portions of these narratives with the core values as formulated by the Royal Dutch Pharmacists Association. Other values that emerged were inductively coded and if possible used to further customise the respective core values.

Key findings

The expert panel identified all four professional core values, that is, commitment to the patient's well‐being (117, 91.4%), reliable and caring (116, 90.6%), pharmaceutical expertise (72, 56.2%) and responsibility to society (30, 23.4%) in the 128 moral dilemma narratives. Thirteen other values that emerged in the analysis could all be used for the customisation of the professional core values in descriptions that better reflect community pharmacy practice.

Conclusions

Professional core values were identified in moral dilemma narratives of pharmacists in community pharmacy and customised for their practice. These customised core values can enable pharmacists to better recognise moral dilemmas in practice. This can add to the advancement of the profession as a pharmaceutical care practice.

Humanization of critical care-psychological effects on healthcare professionals and relatives: a systematic review

PURPOSE

To systematically review and evaluate the effects of humanized care of the critically ill on empathy among healthcare professionals, anxiety among relatives, and burnout and compassion fatigue in both groups.

SOURCE

MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and ProQuest Dissertations were searched from inception to 29 June 2017 for studies that investigated the effects of interventions with potential to humanize care of the critically ill on the following outcomes: empathy among critical care professionals, anxiety among relatives, and burnout and compassion fatigue in either group. We defined a humanizing intervention as one with substantial potential to increase physical or emotional proximity to the patient. Two reviewers independently selected studies, extracted data, and assessed risk of bias and data quality.

PRINCIPAL FINDINGS

Twelve studies addressing four discrete interventions (liberal visitation, diaries, family participation in basic care, and witnessed resuscitation) and one mixed intervention were included. Ten studies measured anxiety among 1,055 relatives. Two studies measured burnout in 288 critical care professionals. None addressed empathy or compassion fatigue. Eleven of the included studies had an overall high risk of bias. No pooled estimates of effect were calculated as a priori criteria for data synthesis were not met.

CONCLUSIONS

We found insufficient evidence to make any quantitative assessment of the effect of humanizing interventions on any of these psychologic outcomes. We observed a trend towards reduced anxiety among family members who participated in basic patient care, liberal visitation, and diary keeping. We found conflicting effects of liberal visitation on burnout among healthcare professionals.

Moral distress and moral competences in midwifery: A latent variable approach

Like other health professionals, midwives need moral competences in order to cope effectively with ethical issues and to prevent moral distress and negative consequences such as fatigue or impaired quality of care. In this study, we developed and conducted a survey with 280 midwives or midwifery students assessing the burden associated with ethical issues, moral competences, and negative consequences of moral distress. Results show that ethical issues associated with asymmetries of power and authority most often lead to the experience of distress. The results are critically discussed in the context of the conceptualization and operationalization of moral distress.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth

BACKGROUND

Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada.

METHODS

Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care.

RESULTS

Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43).

CONCLUSIONS

Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

Moral distress in healthcare assistants: A discussion with recommendations

BACKGROUND

Moral distress can be broadly described as the psychological distress that can develop in response to a morally challenging event. In the context of healthcare, its effects are well documented in the nursing profession, but there is a paucity of research exploring its relevance to healthcare assistants.

OBJECTIVE

This article aims to examine the existing research on moral distress in healthcare assistants, identity the important factors that are likely to contribute to moral distress, and propose preventative measures.

RESEARCH DESIGN

This is a survey of the existing literature on moral distress in healthcare assistants. It uses insights from moral distress in nursing to argue that healthcare assistants are also likely to experience moral distress in certain contexts.

PARTICIPANTS AND RESEARCH CONTEXT

No research participants were part of this analysis.

ETHICAL CONSIDERATIONS

This article offers a conceptual analysis and recommendations only.

FINDINGS

The analysis identifies certain factors that may be particularly applicable to healthcare assistants such as powerlessness and a lack of ethical knowledge. We demonstrate that these factors contribute to moral distress.

DISCUSSION

Recommendations include various preventative measures such as regular reflective debriefing sessions involving healthcare assistants, nurses and other clinicians, joint workplace ethical training, and modifications to the Care Certificate. Implementation of these measures should be monitored carefully and the results published to augment our existing knowledge of moral distress in healthcare assistants.

CONCLUSION

This analysis establishes the need for more research and discussion on this topic. Future research should focus on evaluating the effectiveness of the proposed recommendations.

Emergency department mortality: Fair and square

OBJECTIVE

This study explored the therapeutic approaches used for end-of-life (EOL) patients admitted to the emergency department (ED) and examined whether the decision to perform life-extending treatment (LET) or to allow natural death (AND) depends on patient characteristics, medical staff variables, and ED setting.

METHODS

A retrospective archive study was conducted from January 2015 to December 2017 in the ED of a tertiary hospital. The study sample were 674 EOL patients who had died in the ED. For each patient, data were collected and measured for dying process (LET vs. AND), patient characteristics, ED-setting variables, and medical-staff characteristics.

RESULTS

The proportion of EOL patients undergoing LET increased from 18.1% in 2015 to 25.9% in 2016 and to 30.3% in 2017 (p = .010), and a quarter of them were treated by emergency medical services. Males tended to receive LET more than females (p < .001). An association was found between Jewish physicians and nurses and AND (p = .001). Heavier workload in the ED and greater severity of the triage classification predicted more LET (OR-1.67, CI = 1.05-1.76, p = .003 and OR = 1.42, CI-0.60-0.81, p < .001, respectively). Receiver operating characteristic analysis showed that patient characteristics contributed most crucially to the therapeutic approaches (C statistic 0.624-0.675, CI-0.62-0.71).

CONCLUSIONS

The therapeutic approach used for EOL patients in the ED depends on variables in all three treatment layers: patient, medical staff, and ED setting. Applicable national programs should be developed to ensure that no external factors influence the dying-process decision.

Phenomenon of moral distress through the aspect of interpretive interactionism

BACKGROUND

Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture.

RESEARCH OBJECTIVE

To analyze the main causes for moral distress with interpretive interactionism.

RESEARCH DESIGN

A qualitative study was adopted.

PARTICIPANTS

Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples.

ETHICAL CONSIDERATIONS

Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital.

FINDINGS

Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress.

DISCUSSION

The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care.

CONCLUSION

The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

A survey of moral distress in certified registered nurse anesthetists: A theoretical perspective for change in ethics education for advance practice nurses

OBJECTIVE

The aim of this study was to examine the relationship between moral distress that may affect patient safety, and the clinical practice model, assessing ethical decision-making skills of certified registered nurse anesthetists (CRNAs).

METHODS

A survey using the Ethical Stress Scale (ESS) and the Ethical Assessment Skills Survey (EASS) was conducted with 134 CRNAs.

RESULTS

Results indicated no significant effect of practice model on level of moral distress or perceived ethical assessment skill knowledge [Wilks's lambda = 0.952, F (6, 256) = 1.068, P = 0.382, n 2  = 0.02]. A statistically significant positive correlation existed between importance and skill (r = 0.275, P = 0.001). CRNAs felt skilled to manage the actions or activities they deemed important.

CONCLUSION

CRNAs who perceived a higher skill level in addressing ethical issues experienced lower levels of moral distress. Findings indicate content-specific curricula for the CRNAs need to be evaluated for ethical decision-making skill assessment content.

Navigating the Dangerous Terrain of Moral Distress: Understanding Response Patterns in the NICU

Moral distress is a well-recognized and ubiquitous aspect of health care professional practice in the neonatal intensive care unit (NICU) context. We used interpretive description methodology to guide a critical exploration of the dynamics of moral distress experience as reflected in the accounts of 28 health care professionals working in this setting. We learned about the kinds of clinical scenarios which triggered distressing experiences, and that the organizational and relational context of clinical work constituted a complex and dynamic working environment that profoundly affected both the individual and the collective experiences with moral distress in these situations. These findings shed light on possibilities for supporting NICU practitioners and developing the collaborative team cultures that may reduce the risk of unresolved effects of moral distress to the benefit of patients as well as the professionals who care for them.

Physical therapists' perception of workplace ethics in an evolving health-care delivery environment: a cross-sectional survey

Physical therapists are trained and obligated to deliver optimal health care and put patients first above all else. In the changing health-care environment, health-care organizations are grappling with controlling cost and increasing revenues. Moral distress may be created when physical therapists' desire to provide optimal care conflicts with their organization's goals to remain financially viable or profitable. Moral distress has been associated with low perception of ethical environment, professional burnout, and high turnover in organizations. This study identified groups who may be vulnerable to low perception of organizational ethical environment and identified self-reported strategies to remedy these perceptions. An ethics environment questionnaire was mailed to a random sample of 1200 physical therapists in Georgia. Respondents (n = 340) were analyzed by age, workplace setting, and position in organization. Therapists working in skilled nursing/assisted living environments scored the lowest on the questionnaire and voiced concerns regarding their ethical work environments. Owners and executives perceived their organizations to be more ethical than front-line clinicians. Respondent concerns included high productivity standards, aggressive coding/billing policies, decreased reimbursement, and increased insurance regulation. Possible solutions included more frequent communication between management and clinicians about ethics, greater professional autonomy, and increased training in business ethics and finance.

Exploring moral problems and moral competences in midwifery: A qualitative study

Background:

Most undergraduate midwifery curricula comprise ethics courses to strengthen the moral competences of future midwives. By contrast, surprisingly little is known about the specific moral competences considered to be relevant for midwifery practice. Describing these competences not only depends on generic assumptions about the moral nature of midwifery practice but also reflects which issues practitioners themselves classify as moral.

Objective:

The goal of this study was to gain insight into the ethical issues midwives encounter in their daily work, the key competences and resources they consider indispensable to understand and deal with them, and to assess phenomena linked to moral distress.

Methods:

We conducted individual semi-structured interviews with eight midwives and two other health professionals, varying in terms of years of experience and work setting. Interview transcripts were analyzed in an interdisciplinary research group, following thematic analysis.

Ethical considerations:

This study was not subject to approval according to the Swiss Law on Research with Humans. Participants were informed about the study goals and gave written informed consent prior to participation.

Results:

External constraints limiting the midwife’s and the patient’s autonomy and resulting interpersonal conflicts were found to be the most relevant ethical issues encountered in clinical practice and were most often associated with moral distress. These conflicts often arise in the context of medical interventions midwives consider as not appropriate and situations in which less experienced midwives in particular observe a lack of both interprofessional communication and trust in their professional competence. Ethical issues related to late abortions or prenatal diagnostics and selective abortions were also frequently addressed, but many midwives involved had learned to cope with them.

Discussion:

In the light of the ethical issues and factors contributing to phenomena of moral distress, an empirically grounded profile of moral competences is drafted. Curricular implications in the light of possible adaptations within undergraduate midwifery education are critically discussed.

Interprofessionals' definitions of moral resilience

AIMS AND OBJECTIVES

To describe common characteristics and themes of the concept of moral resilience as reported by interprofessional clinicians in health care.

BACKGROUND

Research has provided an abundance of data on moral distress with limited research to resolve and help negate the detrimental effects of moral distress. This reveals a critical need for research on how to mitigate the negative consequences of moral distress that plague nurses and other healthcare providers. One promising direction is to build resilience as an individual strategy concurrently with interventions to build a culture of ethical practice.

DESIGN/METHODS

Qualitative descriptive methods were used to analyse descriptive definitions provided by 184 interprofessional clinicians in health care attending educational programmes in various locations as well as a small group of 23 professionals with backgrounds such as chaplaincy and nonhealthcare providers.

RESULTS

Three primary themes and three subthemes emerged from the data. The primary themes are integrity-personal and relational, and buoyancy. The subthemes are self-regulation, self-stewardship and moral efficacy.

CONCLUSIONS

Individual healthcare providers and healthcare systems can use this research to help negate the detrimental effects of moral distress by finding ways to develop interventions to cultivate moral resilience.

RELEVANCE TO CLINICAL PRACTICE

Moral resilience involves not only building and fostering the individual's capacity to navigate moral adversity but also developing systems that support a culture of ethical practice for healthcare providers.

Vulnerability, survival and shame in Nina Raine's Tiger Country

Shame in healthcare remains relatively underexplored, yet it is commonplace and its impact is significant. This paper explores shame in healthcare using Nina Raine's 2011 play Tiger Country Three manifestations of shame are explored, namely (1) shame in relation to professional identity and survival in the clinical workplace; (2) shame and illness as experienced by both patients and doctors; and (3) the systemic and organisational influences on shame within healthcare systems. I suggest that the theatre is particularly well-placed to elucidate shame, and that Tiger Country demonstrates the prevalence and impact of shame on clinical work. Shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health. Attention to shame is essential for those interested in medicine and healthcare and must, I propose, include the experiences and perceptions of those who provide care, as well as attending to those who receive care.

Analysis and evaluation of the moral distress theory

Moral distress is a pervasive problem in nursing resulting in a detriment to patient care, providers, and organizations. Over a decade ago, the moral distress theory (MDT) was proposed and utilized in multiple research studies. This middle range theory explains and predicts the distress that occurs in a nurse because of moral conflict. The research findings born from this theory have been substantial. Since inception of this theory, moral distress has been extensively examined which has further elaborated its understanding. This paper provides an analysis and evaluation of the MDT according to applicable guidelines. Current understanding of the phenomenon indicates that a new theory may be warranted to better predict, treat, and manage moral distress.