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Thomas TA, Kumar S, Davis FD, Boedeker P, Thammasitboon S. Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals. AJOB Empir Bioeth 2024:1-13. [PMID: 38165288 DOI: 10.1080/23294515.2023.2297922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress. DESIGN Cross-sectional survey. SETTING Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States. PARTICIPANTS Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study. MAIN OUTCOME MEASURES Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM). RESULTS Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82). CONCLUSIONS We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.
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Affiliation(s)
- Tessy A Thomas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Health System, Danville, PA, USA
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Shelley Kumar
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - F Daniel Davis
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Peter Boedeker
- Department of Education, Innovation and Technology, Baylor College of Medicine, Houston, TX, USA
| | - Satid Thammasitboon
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Ravaldi C, Mosconi L, Mannetti L, Checconi M, Bonaiuti R, Ricca V, Mosca F, Dani C, Vannacci A. Post-traumatic stress symptoms and burnout in healthcare professionals working in neonatal intensive care units: Results from the STRONG study. Front Psychiatry 2023; 14:1050236. [PMID: 36816403 PMCID: PMC9935564 DOI: 10.3389/fpsyt.2023.1050236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/13/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Newborns' deaths and life-threatening conditions represent extremely stressful events for parents and professionals working in NICUs, facilitating the onset of secondary traumatic stress symptoms. The STRONG study aims to better understand the psychological impact on Italian NICUs staff of bereavement care. METHODS The STRONG (STress afteR lOss in NeonatoloGy) study is a cross-sectional study based on a web survey consisted of four sections: sociodemographic, CommuniCARE-Newborn questionnaire, the Maslach Burnout Inventory and the Impact of Event Scale-Revised. RESULTS 227 NICU workers (42.7% nurses, 23.3% midwives, 22.2% physicians, 11.8% other HCPs) answered the survey. The hardest tasks were "communicating baby's death" and "informing on autopsy results"; 44.7% of HCPs did not receive formal training in communicating bad news, 44.2% 'learned from the field' by watching other colleagues; 41.2% declared that they do not have any communication strategy. More than 90% of professionals thought that training on bereavement care is necessary. The majority of HCPs showed some degree of post-traumatic stress symptoms: 34% medium and 35.3% severe. Professionals with training in bereavement care and/or in communication had less probability to develop stress symptoms. A multivariate analysis showed that higher levels of burnout were associated with 4 or more monthly losses and medium or severe stress symptoms. Having a well-defined communication strategy for breaking bad news was independently associated with a better personal accomplishment. CONCLUSION Dealing with newborns' deaths is a highly stressful task; professionals should receive proper support such as debriefing, psychological support and training in order to prevent post-traumatic stress symptoms and reduce professional burnout.
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Affiliation(s)
- C Ravaldi
- CiaoLapo Foundation for Perinatal Health, Prato, Italy.,PeaRL - Perinatal Research Laboratory, Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - L Mosconi
- CiaoLapo Foundation for Perinatal Health, Prato, Italy
| | - L Mannetti
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - M Checconi
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - R Bonaiuti
- CiaoLapo Foundation for Perinatal Health, Prato, Italy.,PeaRL - Perinatal Research Laboratory, Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - V Ricca
- Department of Health Sciences, Psychiatry Unit, Careggi General Hospital, University of Florence, Florence, Italy
| | - F Mosca
- Department of Pediatrics, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Italian Society of Neonatology (SIN), Milan, Italy
| | - C Dani
- PeaRL - Perinatal Research Laboratory, Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - A Vannacci
- CiaoLapo Foundation for Perinatal Health, Prato, Italy.,PeaRL - Perinatal Research Laboratory, Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
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Carletto S, Ariotti MC, Garelli G, Di Noto L, Berchialla P, Malandrone F, Guardione R, Boarino F, Campagnoli MF, Savant Levet P, Bertino E, Ostacoli L, Coscia A. Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148526. [PMID: 35886379 PMCID: PMC9323986 DOI: 10.3390/ijerph19148526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022]
Abstract
Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.
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Affiliation(s)
- Sara Carletto
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, 10126 Turin, TO, Italy;
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
| | - Maria Chiara Ariotti
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
| | - Giulia Garelli
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
| | - Ludovica Di Noto
- Formerly at the School of Medicine, University of Torino, 10126 Turin, TO, Italy;
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
| | - Francesca Malandrone
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
- Correspondence:
| | - Roberta Guardione
- Neonatal Care Unit, City of Health and Science University Hospital of Torino, 10126 Turin, TO, Italy; (R.G.); (M.F.C.)
| | - Floriana Boarino
- Neonatal Care Unit, Santa Croce Hospital ASL TO5, 10024 Moncalieri, TO, Italy;
| | - Maria Francesca Campagnoli
- Neonatal Care Unit, City of Health and Science University Hospital of Torino, 10126 Turin, TO, Italy; (R.G.); (M.F.C.)
| | - Patrizia Savant Levet
- Neonatal Intensive Care Unit, Maria Vittoria Hospital, ASL Città di Torino, 10144 Turin, TO, Italy;
| | - Enrico Bertino
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
| | - Luca Ostacoli
- Clinical Psychology Unit, A.O.U. City of Health and Science of Torino, 10126 Turin, TO, Italy; (G.G.); (L.O.)
- Department of Clinical and Biological Sciences, University of Torino, 10043 Turin, TO, Italy;
| | - Alessandra Coscia
- Neonatal Intensive Care Unit of University of Torino, Sant’Anna Hospital, City of Health and Science, 10126 Turin, TO, Italy; (M.C.A.); (E.B.); (A.C.)
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Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study. J Perinatol 2022; 42:476-482. [PMID: 34504300 DOI: 10.1038/s41372-021-01203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/27/2021] [Accepted: 08/25/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence. STUDY DESIGN We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules. RESULTS Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas. CONCLUSIONS After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.
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Prentice TM, Gillam L, Davis PG, Janvier A. Whom are we seeking to protect? Extremely preterm babies and moral distress. Semin Perinatol 2022; 46:151549. [PMID: 34887107 DOI: 10.1016/j.semperi.2021.151549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Advances in perinatal care bring with them ethical challenges and difficult questions. When should we provide life-sustaining interventions, and who should decide? Particularly at the edges of viability, some clinicians may feel required to provide a level of care that they believe is not in the patient's interests, resulting in moral distress. This article will discuss the complex nature of moral distress arising during the care of extremely preterm babies. It will describe the challenges and cognitive biases present when contemplating potential harms to the baby and recognize the possible costs to both healthcare provider and baby when moral distress arises. Both clinicians caring for extremely preterm babies and the families themselves can experience moral distress. This article argues that for clinicians, recognizing the range of possible sources of moral distress is vital in order to appropriately address moral distress. Moral distress may arise from a desire to protect the baby, but also from an impulse to protect oneself from the emotional burdens of care. Addressing moral distress requires reflection on the factual beliefs, experiences and personal values which lie behind the distress, both within oneself and in discussion with colleagues. Moral distress indicates that a situation is ethically challenging, but it does not necessarily mean that a wrong decision has been made.
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Affiliation(s)
- Trisha M Prentice
- Neonatal Medicine, Royal Children's Hospital, 50 Flemington Rd, Victoria, Melbourne, Australia; Murdoch Children's Research Institute, Victoria, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Melbourne, Australia; Children's Bioethics Centre, Royal Children's Hospital, Victoria, Melbourne, Australia
| | - Peter G Davis
- Women's Newborn Research Centre, Royal Women's Hospital, Victoria, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Melbourne, Australia
| | - Annie Janvier
- Department of Pediatrics, Division of Neonatology, Clinical Ethics Unit, Palliative Care Unit, Unité de Recherche en Éthique Clinique et Partenariat Famille, CHU Ste-Justine, Québec, Montréal, Canada; Department of Pediatrics and Clinical Ethics, Université de Montréal, Québec, Montréal, Canada
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Wilson CA, Metwally H, Heavner S, Kennedy AB, Britt TW. Chronicling moral distress among healthcare providers during the COVID-19 pandemic: A longitudinal analysis of mental health strain, burnout, and maladaptive coping behaviours. Int J Ment Health Nurs 2022; 31:111-127. [PMID: 34644443 PMCID: PMC8653372 DOI: 10.1111/inm.12942] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
The COVID-19 pandemic has presented many novel situations that have amplified the presence of moral distress in healthcare. With limited resources to protect themselves against the virus and strict safety regulations that alter the way they work, healthcare providers have felt forced to engage in work behaviours that conflicted with their professional and personal sense of right and wrong. Although many providers have experienced moral distress while being physically in the workplace, others suffered while at home. Some healthcare providers worked in facilities that were unable to open during the pandemic due to restrictions, which could contribute to a sense of powerlessness and guilt. The current study assessed whether the ability to see patients each week impacted the relationship between an employee's moral distress and their mental health strain, burnout, and maladaptive coping. A total of 378 healthcare providers responded to weekly surveys over the course of 7 months (April 2020-December 2020). Hierarchical linear modeling techniques were used to examine the study variables over time. Results showed that moral distress predicted an individual's mental health strain and burnout, even after controlling for the prior week. However, moral distress was not a significant predictor of maladaptive coping. Interestingly, there was not a significant difference between the average ratings of moral distress between those who were able, and those who were not able to see patients, meaning that both groups experienced symptoms of moral distress. However, cross-level moderation results indicated that the ability to see patients magnified the relationships between moral distress and mental health strain and burnout over time. Implications of the results and recommendations for how moral distress should be addressed among healthcare providers are discussed.
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Affiliation(s)
| | | | | | - Ann Blair Kennedy
- University of South Carolina School of Medicine Greenville Campus, Greenville, South Carolina, USA
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Mazzotta R, De Maria M, Bove D, Badolamenti S, Saraiva Bordignon S, Silveira LCJ, Vellone E, Alvaro R, Bulfone G. Moral distress in nursing students: Cultural adaptation and validation study. Nurs Ethics 2021; 29:384-401. [PMID: 34809509 DOI: 10.1177/09697330211030671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral distress, defined as moral suffering or a psychological imbalance, can affect nursing students. However, many new instruments or adaptations of other scales that are typically used to measure moral distress have not been used for nursing students. AIM This study aimed to translate, culturally adapt and evaluate the psychometric properties of an Italian version of the Moral Distress Scale for Nursing Students (It-ESMEE) for use with delayed nursing students (students who could not graduate on time or failed the exams necessary to progress to the next level). RESEARCH DESIGN The study used a cross-sectional research design. PARTICIPANTS AND RESEARCH CONTEXT Incidental sampling resulted in a sample of 282 delayed nursing students (mean age = 26.73 ± 4.43 years, 73% female) enrolled between May and August 2020 in a University of central Italy. ETHICAL CONSIDERATIONS The research protocol was approved by the internal review board of the university, and all participants provided their written informed consent. RESULTS The study confirmed a multidimensional second-order factorial structure for the It-ESMEE with five dimensions: improper institutional conditions to teach user care, authoritarian teaching practices, disrespect for the ethical dimension of vocational training, lack of competence of the teacher and commitment of ethical dimension of user care. The internal consistency was high (0.753-0.990 across the factors), and the standard error of measurement and smallest detectable change were adequate. DISCUSSION The It-ESMEE is able to assess moral distress in delayed nursing students with good validity and reliability. It can be used in research and to determine moral distress levels, helping teachers to monitor the condition in nursing students. CONCLUSION This instrument can help in comprehending moral distress, enabling students to develop coping and intervention strategies to maintain their well-being, and to ensure the quality of nurse education.
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Foster W, McKellar L, Fleet JA, Sweet L. Exploring moral distress in Australian midwifery practice. Women Birth 2021; 35:349-359. [PMID: 34654667 DOI: 10.1016/j.wombi.2021.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/11/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
PROBLEM Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. BACKGROUND Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. AIM To explore Australian midwives experience and consequences of moral distress. METHODS Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. FINDINGS Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. DISCUSSION It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. CONCLUSION This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.
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Affiliation(s)
- Wendy Foster
- Clinical and Health Sciences, University of South Australia, Australia; College of Nursing and Health Sciences, Flinders University, Australia.
| | - Lois McKellar
- Clinical and Health Sciences, University of South Australia, Australia. https://www.twitter.com/@DrLoisMcKellar1
| | - Julie-Anne Fleet
- Clinical and Health Sciences, University of South Australia, Australia. https://www.twitter.com/@DrJulieFleet
| | - Linda Sweet
- College of Nursing and Health Sciences, Flinders University, Australia; School of Nursing and Midwifery, Deakin University and Western Health Partnership, Australia. https://www.twitter.com/@ProfLindaSweet
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Abstract
Summary: Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.
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Prentice TM, Janvier A, Gillam L, Donath S, Davis PG. Moral Distress in Neonatology. Pediatrics 2021; 148:peds.2020-031864. [PMID: 34285081 DOI: 10.1542/peds.2020-031864] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To longitudinally examine the nature of moral distress (MoD) experienced by clinicians caring for extremely low gestational age neonates. METHODS Neonatologists, medical trainees, and nurses were surveyed at regular intervals on their experience of MoD and their preferred level of care in relation to 99 neonates born <28 weeks' gestational age managed from birth until discharge or death in 2 tertiary NICUs. Clinicians reporting significant distress (≥6 of 10 on Wocial's Moral Distress Thermometer) were asked to provide open-ended responses on why they experienced MoD. Descriptive statistics were used to analyze frequency and intensity of MoD across different clinician characteristics. Open-ended responses were analyzed by using mixed methods. RESULTS Over 18 months, 4593 of 5332 surveys (86% response rate) were collected. MoD was reported on 687 (15%) survey occasions; 91% of neonates elicited MoD during their hospitalization. In their open-ended answers, clinicians invoked 5 main themes to explain their distress: (1) infant-centered reasons (83%), including illness severity, predicted outcomes, and disproportionate care; (2) management plans (26%); (3) family-centered reasons (19%); (4) parental decision-making (16%); and (5) provider-centered reasons (15%). MoD was strongly associated with the perception of "parents wanting too much." Neonatologists experienced less distress and were more likely than nurses and trainees to align preferred levels of care with family wishes. CONCLUSIONS The majority of preterm infants will generate some MoD; however, it is rarely shared and of a sustained nature. The main constraint reported by clinicians was "parents wanting too much," leading to disproportionate care.
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Affiliation(s)
- Trisha M Prentice
- Department of Neonatal Medicine .,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Departments of Paediatrics
| | - Annie Janvier
- Clinical Ethics and Palliative Care Units, Unité de Recherche en Éthique Clinique et Partenariat Famille, Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pediatrics and Clinical Ethics, Université de Montréal, Montreal, Quebec, Canada
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Departments of Paediatrics
| | - Peter G Davis
- Newborn Research, Royal Women's Hospital, Melbourne, Victoria, Australia.,Obstetrics and Gynaecology, Melbourne Medical School
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11
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Doherty J, O'Brien D. A participatory action research study exploring midwives' understandings of the concept of burnout in Ireland. Women Birth 2021; 35:e163-e171. [PMID: 34130937 DOI: 10.1016/j.wombi.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In depth exploration of the burnout phenomenon among midwives is sparse. The concept has been extensively studied, but predominantly reports rates and evaluates interventions to reduce burnout. A definition has yet to be offered in the literature from a midwifery perspective. AIMS To explore midwives' understandings of burnout, professionally and personally, in the context of contemporary maternity care in Ireland. METHODS This was a Two-phase Participatory Action Research study. Five co-operative inquiry meetings were held with practising midwives (n=21) over a six-month period between October 2018 and March 2019, in a large, urban teaching maternity hospital in Dublin, Ireland. FINDINGS We found that multiple factors contributed to midwives' perceptions and understandings of the concept of burnout. Midwives defined burnout as persistent stress and exhaustion, with an associated reduction of their individual coping abilities, motivation, empathy and/or efficacy, is unique to the individual and is primarily, in the midwifery context, caused and inextricably linked to excessive workload. CONCLUSION Burnout is a complex concept with many entities and its significance and impact within the midwifery profession highlights the importance of its exploration and understanding. This study is the first of its kind to explore, with midwives, the concept of burnout. The elements of stress and exhaustion in the definition mirror existing definitions in the literature.
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Affiliation(s)
- Jean Doherty
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Denise O'Brien
- School of Nursing, Midwifery & Health Systems, University College Dublin, Belfield, Dublin 4, Ireland.
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12
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Silverman HJ, Kheirbek RE, Moscou-Jackson G, Day J. Moral distress in nurses caring for patients with Covid-19. Nurs Ethics 2021; 28:1137-1164. [PMID: 33910406 DOI: 10.1177/09697330211003217] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Jenni Day
- 1479University of Maryland Medical Center, USA
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Ducharlet K, Philip J, Gock H, Brown M, Gelfand SL, Josland EA, Brennan F. Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care. Am J Kidney Dis 2020; 76:248-254. [DOI: 10.1053/j.ajkd.2019.09.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/25/2019] [Indexed: 12/28/2022]
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Mills M, Cortezzo DE. Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It. Front Pediatr 2020; 8:581. [PMID: 33014949 PMCID: PMC7511509 DOI: 10.3389/fped.2020.00581] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/07/2020] [Indexed: 11/13/2022] Open
Abstract
Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.
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Affiliation(s)
- Manisha Mills
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - DonnaMaria E Cortezzo
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Kohlen H. Ethische Fragen der Pflegepraxis im Krankenhaus und Möglichkeiten der Thematisierung. Ethik Med 2019. [DOI: 10.1007/s00481-019-00547-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands. Nurs Ethics 2019; 27:1315-1326. [DOI: 10.1177/0969733019877526] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.
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Kukora S, Keefer P, Pituch K, Firn J. Thematic Analysis of Interprofessional Provider Perceptions of Pediatric Death. J Pediatr Nurs 2019; 47:92-99. [PMID: 31082685 DOI: 10.1016/j.pedn.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE Though provider and patient perceptions of death are characterized in the adult population literature, there is limited information related to providers' perceptions in pediatric and neonatal patients. The purpose of this study was to better understand how interprofessional care team members perceive and experience neonatal and pediatric end-of-life situations. DESIGN AND METHODS This survey questionnaire was administered to interprofessional providers following their participation in an institutional workshop, as part of an ongoing institutional effort to improve end-of-life experiences for patients/family and providers. Interprofessional care providers completed an electronic survey consisting of closed-ended and one open-ended question to elicit their perceptions of their participation in end of life care for a recent neonatal/pediatric patient in the period before the child's death. RESULTS The qualitative analysis of 306 free-text responses commenting on the deaths of 138 patients, contained within 880 completed mixed-method surveys, is described. Thematic analysis of the free text discovered three primary themes from the data: favorable aspects of the death experience, unfavorable aspects of the experience, and combined favorable and unfavorable aspects. Four subthemes contributed to the themes; namely, language, parental presence, trust/rapport in provider relationships and inclusion in decision-making, communication, and culture. CONCLUSIONS Multiple factors contribute to how interprofessional care providers perceive end-of-life care experiences for neonatal/pediatric patients. The same death may be perceived differently by different providers. PRACTICE IMPLICATIONS Understanding favorable and unfavorable aspects of providing end-of-life care will support strategies to provide resources, education and support to facilitate coping and resiliency in care providers.
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Affiliation(s)
- Stephanie Kukora
- University of Michigan Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Ann Arbor, United States of America; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, United States of America.
| | - Patricia Keefer
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America; Stepping Stones Pediatric Palliative Care Program, University of Michigan Department of Pediatrics, Ann Arbor, MI, United States of America
| | - Kenneth Pituch
- Stepping Stones Pediatric Palliative Care Program, University of Michigan Department of Pediatrics, Ann Arbor, MI, United States of America
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, United States of America; Department of Learning Health Sciences, Division of Professional Education, University of Michigan Medical School, Ann Arbor, MI, United States of America
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Hudon A, Ehrmann Feldman D, Hunt M. Tensions Living Out Professional Values for Physical Therapists Treating Injured Workers. QUALITATIVE HEALTH RESEARCH 2019; 29:876-888. [PMID: 30304990 DOI: 10.1177/1049732318803589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Anne Hudon
- 1 University of Waterloo, Waterloo, Ontario, Canada
- 2 University of Ottawa, Ottawa, Ontario, Canada
| | - Debbie Ehrmann Feldman
- 3 University of Montreal, Montreal, Québec, Canada
- 4 Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Québec, Canada
| | - Matthew Hunt
- 4 Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Québec, Canada
- 5 McGill University, Montreal, Québec, Canada
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Hanks RG, Eloi H, Stafford L. Understanding how advanced practice registered nurses function as patient advocates. Nurs Forum 2019; 54:213-219. [PMID: 30561014 DOI: 10.1111/nuf.12319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
Although patient advocacy experiences for registered nurses (RNs) have been researched over the past 40 years, very little is known about patient advocacy at the advanced practice registered nursing (APRN) level. The APRN role is distinct from the RN role, in that APRNs are focused on diagnosing, prescribing, and management of treatment of various medical conditions in the settings where APRNs are used. The purpose of this study was to explore the APRN's experience with patient advocacy using a phenomenology-based qualitative design. A total of seven Texas APRNs were randomly selected for participation in telephone interviews. Interview transcripts were analyzed by the research team for repetitive statements and four themes emerged from the data: (a) patients with APRN advocacy is providing resources, information, and protection; (b) outcomes of patient with APRN advocacy: positive and negative; (c) patient advocacy mostly experientially learned at APRN level; and (d) increased medical knowledge increases advocacy ability. This pilot study provides important preliminary exploratory results regarding APRN advocacy and differentiates it from RN level advocacy. In addition, this study provides significant insight into APRN educational preparation for the APRN advocate role, thus serving as a foundation for improving educational approaches to advocacy.
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Affiliation(s)
- Robert G Hanks
- Department of Graduate Studies, UTHealth Cizik School of Nursing, Houston, Texas
| | - Hildreth Eloi
- Department of Graduate Studies, UTHealth Cizik School of Nursing, Houston, Texas
| | - Linda Stafford
- Department of Graduate Studies, UTHealth Cizik School of Nursing, Houston, Texas
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Ajoudani F, Baghaei R, Lotfi M. Moral distress and burnout in Iranian nurses: The mediating effect of workplace bullying. Nurs Ethics 2018; 26:1834-1847. [PMID: 29938574 DOI: 10.1177/0969733018779210] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral distress and workplace bullying are important issues in the nursing workplace that appear to affect nurse's burnout. AIM To investigate the relationship between moral distress and burnout in Iranian nurses, as mediated by their perceptions of workplace bullying. ETHICAL CONSIDERATIONS The research was approved by the committee of ethics in research of the Urmia University of Medical Sciences. METHOD This is a correlation study using a cross-sectional design with anonymous questionnaires as study instruments (i.e. Moral Distress Scale-Revised, Maslach Burnout Inventory and The Negative Acts Questionnaire-Revised). Data were collected from 278 nurses from five teaching hospitals in Urmia, the capital of Western Azerbaijan, northwest of Iran. Structural equation modeling and bootstrapping procedures were employed to recognize the mediating role of their perceptions of workplace bullying. RESULTS The mean score of moral distress, burnout, and the Negative Acts Questionnaire-Revised Scale among the participants were 91.02 ± 35.26, 79.9 ± 18.27, and 45.4 ± 15.39, respectively. The results confirmed our hypothesized model. All the latent variables of study were significantly correlated in the predicted directions. The moral distress and bullying were significant predictors of burnout. Perception of bullying partially mediated the relationship between moral distress and burnout. The mediating role of the bullying suggests that moral distress increases burnout, directly and indirectly. CONCLUSION Nursing administrators should be conscious of the role of moral distress and bullying in the nursing workplace in increasing burnout.
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Papazoglou K, Chopko B. The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic. Front Psychol 2017; 8:1999. [PMID: 29187830 PMCID: PMC5694767 DOI: 10.3389/fpsyg.2017.01999] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 10/31/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Brian Chopko
- Department of Sociology, Kent State University, North Canton, OH, United States
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Hanks RG, Starnes-Ott K, Stafford L. Patient Advocacy at the APRN Level: A Direction for the Future. Nurs Forum 2017; 53:5-11. [PMID: 28398600 DOI: 10.1111/nuf.12209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient advocacy is seen as a critical role for the nursing profession. Although there is an existing body of literature surrounding the registered nurse level of patient advocacy, little is known about the advanced practice registered nurse (APRN) and patient advocacy. This article examines the existing patient advocacy research literature and existing APRN competencies to provide direction for further research.
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Affiliation(s)
- Robert G Hanks
- University of Texas Health Science Center-Houston School of Nursing, Houston, TX
| | - Kristen Starnes-Ott
- University of Texas Health Science Center-Houston School of Nursing, Houston, TX
| | - Linda Stafford
- University of Texas Health Science Center-Houston School of Nursing, Houston, TX
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Udod S. Seeking Connectivity in Nurses' Work Environments: Advancing Nurse Empowerment Theory. Can J Nurs Res 2017; 46:110-127. [PMID: 29509488 DOI: 10.1177/084456211404600307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to investigate how staff nurses and their managers exercise power in a hospital setting in order to better understand what fosters or constrains staff nurses' empowerment and to extend nurse empowerment theory. Power is integral to empowerment, and attention to the challenges in nurses' work environment and nurse outcomes by administrators, researchers, and policy-makers has created an imperative to advance a theoretical understanding of power in the nurse-manager relationship. A sample of 26 staff nurses on 3 units of a tertiary hospital in western Canada were observed and interviewed about how the manager affected their ability to do their work. Grounded theory methodology was used. The process of seeking connectivity was the basic social process, indicating that the manager plays a critical role in the work environment and nurses need the manager to share power with them in the provision of safe, quality patient care.
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Affiliation(s)
- Sonia Udod
- College of Nursing, University of Saskatchewan, Saskatoon, Canada
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Ford NJ, Austin W. Conflicts of conscience in the neonatal intensive care unit: Perspectives of Alberta. Nurs Ethics 2017; 25:992-1003. [DOI: 10.1177/0969733016684547] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection.
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Brailey S, Luyben A, van Teijlingen E, Frith L. Women, Midwives, and a Medical Model of Maternity Care in Switzerland. INTERNATIONAL JOURNAL OF CHILDBIRTH 2017. [DOI: 10.1891/2156-5287.7.3.117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article presents a case study on the organization of maternity health care in Switzerland. Switzerland has a costly health care system with high intervention rates within an obstetric-led maternity care model. Evidence has shown that midwifery care is associated with lower cost, higher satisfaction rates among women, and less intervention. However, in this model, midwives are both marginalized and underused.The article focuses on the distribution of power and knowledge between midwives, women, and the medical profession. The varying power structures that shape the maternity care system in Switzerland are examined, using a case study approach that draws on Foucault’s concepts of the gaze, surveillance, disciplinary power, and the docile body. This article critically analyzes the model of maternity care received by women in Switzerland and how it negatively impacts on both women’s personal and midwives’ professional autonomy while simultaneously driving up costs.A better understanding of the underlying power structures operating within the maternity care system may facilitate the implementation of more midwifery-led care currently being endorsed by the Swiss Midwifery Association and some government agencies. This could result in reduced cost and lower intervention rates with reduced associated morbidity.
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Water T, Ford K, Spence D, Rasmussen S. Patient advocacy by nurses – past, present and future. Contemp Nurse 2016; 52:696-709. [DOI: 10.1080/10376178.2016.1235981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Tineke Water
- Department of Nursing, Auckland University of Technology, Auckland, New Zealand
| | - Katrina Ford
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Deb Spence
- Department of Nursing, Auckland University of Technology, Auckland, New Zealand
| | - Shayne Rasmussen
- Department of Nursing, Auckland University of Technology, Auckland, New Zealand
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Abstract
This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with moral distress intensity, whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity.
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MESH Headings
- Adult
- Age Factors
- Attitude of Health Personnel
- Burnout, Professional/prevention & control
- Burnout, Professional/psychology
- Conflict, Psychological
- Deception
- Ethics, Nursing
- Factor Analysis, Statistical
- Health Facility Environment/ethics
- Health Facility Environment/organization & administration
- Health Knowledge, Attitudes, Practice
- Humans
- Mid-Atlantic Region
- Morals
- Nurse's Role/psychology
- Nursing Methodology Research
- Nursing Staff, Hospital/ethics
- Nursing Staff, Hospital/organization & administration
- Nursing Staff, Hospital/psychology
- Organizational Culture
- Patient Advocacy/ethics
- Patient Advocacy/psychology
- Personnel Turnover
- Power, Psychological
- Professional Autonomy
- Risk Factors
- Social Responsibility
- Surveys and Questionnaires
- Workplace/organization & administration
- Workplace/psychology
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O'Connor T, Kelly B. Bridging the Gap: a study of general nurses’ perceptions of patient advocacy in Ireland. Nurs Ethics 2016; 12:453-67. [PMID: 16178342 DOI: 10.1191/0969733005ne814oa] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Advocacy has become an accepted and integral attribute of nursing practice. Despite this adoption of advocacy, confusion remains about the precise nature of the concept and how it should be enacted in practice. The aim of this study was to investigate general nurses’ perceptions of being patient advocates in Ireland and how they enact this role. These perceptions were compared with existing theory and research on advocacy in order to contribute to the knowledge base on the subject. An inductive, qualitative approach was used for this study. Three focus group interviews with a total of 20 practising nurses were conducted with a sample representing different grades in a general hospital setting. Data analysis was carried out using elements of Strauss and Corbins’ approach to concept development. The findings indicate that the principal role of the nurse advocate is to act as an intermediary between the patient and the health care environment. The results highlight that advocacy did, however, result in nurses becoming involved in conflict and confrontation with others and that it could be detrimental to nurses both professionally and personally. It was also clear that when enacting advocacy, nurses distinguished between ‘clinical advocacy’ (acting directly for patients in the clinical environment) and organizational advocacy (acting on an organizational level for one or more patients).
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Affiliation(s)
- Tom O'Connor
- School of Nursing and Midwifery, University College Dublin, Belfield, Dublin 4, Republic of Ireland.
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Sasso L, Bagnasco A, Bianchi M, Bressan V, Carnevale F. Moral distress in undergraduate nursing students. Nurs Ethics 2016; 23:523-34. [DOI: 10.1177/0969733015574926] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Nurses and nursing students appear vulnerable to moral distress when faced with ethical dilemmas or decision-making in clinical practice. As a result, they may experience professional dissatisfaction and their relationships with patients, families, and colleagues may be compromised. The impact of moral distress may manifest as anger, feelings of guilt and frustration, a desire to give up the profession, loss of self-esteem, depression, and anxiety. Objectives: The purpose of this review was to describe how dilemmas and environmental, relational, and organizational factors contribute to moral distress in undergraduate student nurses during their clinical experience and professional education. Research design: The research design was a systematic literature review. Method: The search produced a total of 157 articles published between 2004 and 2014. These were screened with the assessment sheet designed by Hawker and colleagues. Four articles matched the search criteria (one quantitative study and three qualitative), and these were separately read and analyzed by the researchers. The process of review and analysis of the data was supervised by a colleague experienced in moral distress who provided an independent quality check. Ethical consideration: Since this was a systematic review, no ethical approval was required. Findings: From the analysis, it emerged that inequalities and healthcare disparities, the relationship with the mentor, and students’ individual characteristics can all impact negatively on the decisions taken and the nursing care provided, generating moral distress. All these factors condition both the clinical experience and learning process, in addition to the professional development and the possible care choices of future nurses. Conclusion: Few studies dealt with moral distress in the setting of nurse education, and there is a knowledge gap related to this phenomenon. The results of this review underline the need for further research regarding interventions that can minimize moral distress in undergraduate nursing students.
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Abstract
Introduction: To meet and take care of people with dementia implicate professional and moral challenges for caregivers. Using force happens daily. However, staff also encounter challenges with the management in the units. Managing the caretaking function is also significant in how caretakers experience working in dementia care. Purpose: The purpose of this study is to explore the caregiver’s experiences with ethical challenges in dementia care settings and the significance of professional leadership in this context. Method: The design is qualitative, and data appear through narrative interviews. A total of 23 caretakers participated in the study. The transcribed interviews were subjected to a phenomenological-hermeneutical interpretation. Ethical considerations: The respondents signed an informed consent for participation prior to the interviews. They were assured anonymity and confidentiality in the publication of the data. Ricoeur’s method for interpretation ensures anonymity as the researcher relates to the data as one collective text. The study is part of a larger research project in ethics, in its entirety approved in line with the Helsinki Convention. Results: The findings show that the caretakers experienced inadequacy. Some of them described a negative work atmosphere where they experienced that their leaders did not take them seriously. Because of this, informal negative sub-groups functioned as an exclusive debriefing arena. Some of the informants described the opposite experience where the leaders actively supported them. Discussion: The analyses of the findings are discussed in light of the concepts of trust and mistrust in leadership. Conclusion: There is a correlation between the leadership and the caregivers’ experience of being in difficult situations.
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Prentice T, Janvier A, Gillam L, Davis PG. Moral distress within neonatal and paediatric intensive care units: a systematic review. Arch Dis Child 2016; 101:701-8. [PMID: 26801075 DOI: 10.1136/archdischild-2015-309410] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/09/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs). DESIGN Pubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care. RESULTS 13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly 'burdensome' and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating 'aggressive care'. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations. CONCLUSIONS Moral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.
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Affiliation(s)
- Trisha Prentice
- Neonatal Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Annie Janvier
- Division of Neonatology and Clinical Ethics, University of Montreal, Montreal, Quebec, Canada
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Lievrouw A, Vanheule S, Deveugele M, Vos M, Pattyn P, Belle V, Benoit D. Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies. Oncol Nurs Forum 2016; 43:505-12. [DOI: 10.1188/16.onf.505-512] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
This article reports the findings from a participatory action research study concerning the experience of Ugandan nurses caring for individuals with HIV illness. Six key informants from government and non-governmental organizations were interviewed using a semistructured format. Six nurses from a large national referral hospital in Kampala, Uganda, participated in 10 focus group meetings during a period of 11 months. In-depth interviews, focus groups, and photovoice were used to collect the data. Findings indicate that nurses faced many challenges in their daily care, including poverty, insufficient resources, fear of contagion, and lack of ongoing education. Nurses experienced moral distress due to the many challenges they faced during the care of their patients. Moral distress may lead nurses to quit their jobs, which would exacerbate the acute shortage of nurses in Uganda. This study provides important knowledge for guiding clinical practice and nursing education in resource-constrained countries like Uganda.
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MESH Headings
- Acquired Immunodeficiency Syndrome/epidemiology
- Acquired Immunodeficiency Syndrome/nursing
- Adaptation, Psychological
- Adult
- Attitude of Health Personnel/ethnology
- Clinical Competence
- Education, Nursing, Continuing
- Empathy
- Equipment and Supplies, Hospital/supply & distribution
- Fear
- Female
- Focus Groups
- Health Knowledge, Attitudes, Practice
- Health Services Research
- Hospitals, Public
- Hospitals, Teaching
- Humans
- Infection Control
- Male
- Nurse's Role/psychology
- Nursing Methodology Research
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/psychology
- Poverty/psychology
- Self Efficacy
- Surveys and Questionnaires
- Uganda/epidemiology
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Jansson BS, Nyamathi A, Heidemann G, Bird M, Ward CR, Brown-Saltzman K, Duan L, Kaplan C. Predicting Levels of Policy Advocacy Engagement Among Acute-Care Health Professionals. Policy Polit Nurs Pract 2016; 17:43-55. [PMID: 27151835 DOI: 10.1177/1527154416644836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aims to describe the factors that predict health professionals' engagement in policy advocacy. The researchers used a cross-sectional research design with a sample of 97 nurses, 94 social workers, and 104 medical residents from eight hospitals in Los Angeles. Bivariate correlations explored whether seven predictor scales were associated with health professionals' policy advocacy engagement and revealed that five of the eight factors were significantly associated with it (p < .05). The factors include patient advocacy engagement, eagerness, skills, tangible support, and organizational receptivity. Regression analysis examined whether the seven scales, when controlling for sociodemographic variables and hospital site, predicted levels of policy advocacy engagement. Results revealed that patient advocacy engagement (p < .001), eagerness (p < .001), skills (p < .01), tangible support (p < .01), perceived effectiveness (p < .05), and organizational receptivity (p < .05) all predicted health professional's policy advocacy engagement. Ethical commitment did not predict policy advocacy engagement. The model explained 36% of the variance in policy advocacy engagement. Limitations of the study and its implications for future research, practice, and policy are discussed.
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Affiliation(s)
- Bruce S Jansson
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Adeline Nyamathi
- School of Nursing, University of California Los Angeles, CA, USA
| | | | - Melissa Bird
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | | | | | - Lei Duan
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Charles Kaplan
- School of Social Work, University of Southern California, Los Angeles, CA, USA
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Abstract
BACKGROUND The role of nurses as patient advocates is one which is well recognised, supported and the subject of a broad body of literature. One of the key impediments to the role of the nurse as patient advocate is the lack of support and legislative frameworks. Within a broad range of activities constituting advocacy, whistleblowing is currently the subject of much discussion in the light of the Mid Staffordshire inquiry in the United Kingdom (UK) and other instances of patient mistreatment. As a result steps to amend existing whistleblowing legislation where it exists or introduce it where it does not are underway. OBJECTIVE This paper traces the development of legislation for advocacy. CONCLUSION The authors argue that while any legislation supporting advocacy is welcome, legislation on its own will not encourage or enable nurses to whistleblow.
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Monrouxe LV, Rees CE, Dennis I, Wells SE. Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies. BMJ Open 2015; 5:e007518. [PMID: 25991457 PMCID: PMC4442195 DOI: 10.1136/bmjopen-2014-007518] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To understand the prevalence of healthcare students' witnessing or participating in something that they think unethical (professionalism dilemmas) during workplace learning and examine whether differences exist in moral distress intensity resulting from these experiences according to gender and the frequency of occurrence. DESIGN Two cross-sectional online questionnaires of UK medical (study 1) and nursing, dentistry, physiotherapy and pharmacy students (study 2) concerning professionalism dilemmas and subsequent distress for (1) Patient dignity and safety breaches; (2) Valid consent for students' learning on patients; and (3) Negative workplace behaviours (eg, student abuse). PARTICIPANTS AND SETTING 2397 medical (67.4% female) and 1399 other healthcare students (81.1% female) responded. MAIN RESULTS The most commonly encountered professionalism dilemmas were: student abuse and patient dignity and safety dilemmas. Multinomial and logistic regression identified significant effects for gender and frequency of occurrence. In both studies, men were more likely to classify themselves as experiencing no distress; women were more likely to classify themselves as distressed. Two distinct patterns concerning frequency were apparent: (1) Habituation (study 1): less distress with increased exposure to dilemmas 'justified' for learning; (2) Disturbance (studies 1 and 2): more distress with increased exposure to dilemmas that could not be justified. CONCLUSIONS Tomorrow's healthcare practitioners learn within a workplace in which they frequently encounter dilemmas resulting in distress. Gender differences could be respondents acting according to gendered expectations (eg, males downplaying distress because they are expected to appear tough). Habituation to dilemmas suggests students might balance patient autonomy and right to dignity with their own needs to learn for future patient benefit. Disturbance contests the 'accepted' notion that students become less empathic over time. Future research might examine the strategies that students use to manage their distress, to understand how this impacts of issues such as burnout and/or leaving the profession.
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Affiliation(s)
- Lynn V Monrouxe
- Institute of Medical Education, Cardiff University, Cardiff, UK
| | - Charlotte E Rees
- Centre for Medical Education, Medical Education Institute, School of Medicine, University of Dundee, Dundee, UK
| | - Ian Dennis
- School of Psychology, Portland Square, Plymouth University, Plymouth, UK
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Bushby K, Chan J, Druif S, Ho K, Kinsella EA. Ethical tensions in occupational therapy practice: A scoping review. Br J Occup Ther 2015. [DOI: 10.1177/0308022614564770] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Ethical tensions are an unavoidable part of occupational therapy practice. Given the significance of this, and the divergent nature of the literature, a need was identified for a systematic examination of the published literature on this topic. The purpose of this scoping review therefore was to identify, summarize, and describe existing literature on ethical tensions in occupational therapy practice. Method A comprehensive scoping review was conducted. In the initial search, 459 articles, spanning a 13-year time frame, were retrieved from six databases; 32 articles met the criteria for full review. Results Seven themes were identified that highlighted ethical tensions related to: (a) resource and systemic issues; (b) upholding ethical principles and values; (c) client safety; (d) working with vulnerable clients; (e) interpersonal conflicts; (f) upholding professional standards and (g) practice management. Conclusion This scoping review highlights a breadth of ethical tensions that have implications for practice, education, policy and research. It represents an important first step in mapping knowledge about ethical tensions in occupational therapy practice, and lays a foundation for future research directions.
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Affiliation(s)
| | - Jody Chan
- Occupational Therapist, Western University, Canada
| | - Shawna Druif
- Occupational Therapist, Western University, Canada
| | - Kim Ho
- Occupational Therapist, Western University, Canada
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Dalmolin GDL, Lunardi VL, Lunardi GL, Barlem ELD, Silveira RSD. Moral distress and burnout syndrome: are there relationships between these phenomena in nursing workers? Rev Lat Am Enfermagem 2015; 22:35-42. [PMID: 24553701 PMCID: PMC4292705 DOI: 10.1590/0104-1169.3102.2393] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 09/30/2013] [Indexed: 11/22/2022] Open
Abstract
Objective to identify relationships between moral distress and Burnout in the
professional performance from the perceptions of the experiences of nursing
workers. Methods this is a survey type study with 375 nursing workers working in three
different hospitals of southern Rio Grande do Sul, with the application of
adaptations of the Moral Distress Scale and the Maslach Burnout Inventory,
validated and standardized for use in Brazil. Data validation occurred
through factor analysis and Cronbach's alpha. For the data analysis
bivariate analysis using Pearson's correlation and multivariate analysis
using multiple regression were performed. Results the existence of a weak correlation between moral distress and Burnout was
verified. A possible positive correlation between Burnout and therapeutic
obstinacy, and a negative correlation between professional fulfillment and
moral distress were identified. Conclusion the need was identified for further studies that include mediating and
moderating variables that may explain more clearly the models studied.
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Affiliation(s)
- Graziele de Lima Dalmolin
- Universidade Federal de Santa Maria, Departamento de Enfermagem, Santa MariaRS, Brazil, PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Valéria Lerch Lunardi
- Universidade Federal de Santa Maria, Departamento de Enfermagem, Santa MariaRS, Brasil, PhD, Associate Professor, Departamento de Enfermagem, Universidade Federal de Santa Maria, Santa Maria, RS, Brasil
| | - Guilherme Lerch Lunardi
- Universidade Federal do Rio Grande, Instituto de Ciências Econômicas, Administrativas e Contábeis, Rio GrandeRS, Brasil, PhD, Adjunct Professor, Instituto de Ciências Econômicas, Administrativas e Contábeis, Universidade Federal do Rio Grande, Rio Grande, RS, Brasil
| | - Edison Luiz Devos Barlem
- Universidade Federal do Rio Grande, Escola de Enfermagem, Rio GrandeRS, Brasil, PhD, Adjunct Professor, Escola de Enfermagem, Universidade Federal do Rio Grande, Rio Grande, RS, Brasil
| | - Rosemary Silva da Silveira
- Universidade Federal do Rio Grande, Escola de Enfermagem, Rio GrandeRS, Brasil, PhD, Adjunct Professor, Escola de Enfermagem, Universidade Federal do Rio Grande, Rio Grande, RS, Brasil
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Buchbinder M, Lassiter D, Mercier R, Bryant A, Lyerly AD. "Prefacing the Script" as an Ethical Response to State-Mandated Abortion Counseling. AJOB Empir Bioeth 2015; 7:48-55. [PMID: 27570793 DOI: 10.1080/23294515.2015.1019018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Laws governing abortion provision are proliferating throughout the United States, yet little is known about how these laws affect providers. We investigated the experiences of abortion providers in North Carolina practicing under the 2011 Women's Right to Know Act, which mandates that women receive counseling with specific, state-prescribed information at least 24 hours prior to an abortion. We focus here on a subset of the data to examine one strategy by which providers worked to minimize moral conflicts generated by the counseling procedure. Drawing on Erving Goffman's work on language and social interaction, we highlight how providers communicated moral objections and layered meanings through a practice that we call prefacing the script. METHODS We conducted semi-structured interviews with 31 physicians, nurses, physician assistants, and clinic managers who provide abortion care in North Carolina. Audio-recorded interviews were transcribed verbatim and analyzed using an inductive, iterative analytic approach, which included reading for context, interpretive memo-writing, and focused coding. RESULTS Roughly half of the participants (14/31) reported that they or the clinicians who performed the counseling in their institution routinely prefaced the counseling script with qualifiers, disclaimers, and apologies that clarified their relationship to the state-mandated content. We identified three performative functions of this practice: 1) enacting a frame shift from a medical to a legal interaction, 2) distancing the speaker from the authorial voice of the counseling script, and 3) creating emotional alignment. CONCLUSIONS Prefacing state-mandated abortion counseling scripts constitutes a practical strategy providers use to balance the obligation to comply with state law with personal and professional responsibilities to provide tailored care, emotional support, and serve the patient's best interests. Our findings suggest that language constitutes a powerful resource for navigating and minimizing moral conflicts in healthcare.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia St., 341A MacNider Hall CB 7240, Chapel Hill, NC 27599
| | - Dragana Lassiter
- Department of Anthropology, University of North Carolina at Chapel Hill, 301 Alumni Building, CB 3115, Chapel Hill, NC 27510
| | - Rebecca Mercier
- Department of Obstetrics and Gynecology, Jefferson Medical College, 833 Chestnut Street, 1st Floor, Philadelphia, PA 19107
| | - Amy Bryant
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 4002 Old Clinic Building, CB 7570, Chapel Hill, NC 27514
| | - Anne Drapkin Lyerly
- Department of Social Medicine, Center for Bioethics, University of North Carolina at Chapel Hill, 333 S. Columbia St. 333 MacNider Hall CB 7240, Chapel Hill, NC 27599
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Astbury JL, Gallagher CT, O'Neill RC. The issue of moral distress in community pharmacy practice: background and research agenda. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2015; 23:361-6. [PMID: 25639156 DOI: 10.1111/ijpp.12174] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/12/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Moral distress arises from situations in which the individual identifies the morally right action required, but feels unable to act accordingly due to organisational constraints within the work place. Research into this phenomenon has focused predominately on the experience of those in the nursing profession, due to its perceived moral grounding and its traditionally subordinate role. As the conceptual boundaries of moral distress have developed, so too has the research interest in the experiences of other professional groups. Here, we seek to determine if there is scope to study moral distress in pharmacists. METHODS A review of the literature on moral distress in healthcare professions was undertaken. KEY FINDINGS Pharmacists working in the UK operate within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment, when combined with the emerging recognition that pharmacy is a value-based profession with a strong ethical grounding, creates the potential for moral distress to occur due to the limitations placed on acting in congruence with ethical judgements. Studies concerning moral distress in nurses have identified significant negative consequences for both the practitioner and for the quality of patient care. CONCLUSIONS To date, the incidence of moral distress among UK-based community pharmacists remains unexamined. Research must be undertaken to determine what situations cause the highest instances of moral distress for community pharmacists, and the extent to which these pharmacists experience moral distress in their working lives.
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Affiliation(s)
- Jayne L Astbury
- Department of Pharmacy, University of Hertfordshire, Hatfield, UK
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Jansson BS, Nyamathi A, Heidemann G, Duan L, Kaplan C. Predicting Patient Advocacy Engagement: A Multiple Regression Analysis Using Data From Health Professionals in Acute-Care Hospitals. SOCIAL WORK IN HEALTH CARE 2015; 54:559-581. [PMID: 26317762 DOI: 10.1080/00981389.2015.1054059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Although literature documents the need for hospital social workers, nurses, and medical residents to engage in patient advocacy, little information exists about what predicts the extent they do so. This study aims to identify predictors of health professionals' patient advocacy engagement with respect to a broad range of patients' problems. A cross-sectional research design was employed with a sample of 94 social workers, 97 nurses, and 104 medical residents recruited from eight hospitals in Los Angeles. Bivariate correlations explored whether seven scales (Patient Advocacy Eagerness, Ethical Commitment, Skills, Tangible Support, Organizational Receptivity, Belief Other Professionals Engage, and Belief the Hospital Empowers Patients) were associated with patient advocacy engagement, measured by the validated Patient Advocacy Engagement Scale. Regression analysis examined whether these scales, when controlling for sociodemographic and setting variables, predicted patient advocacy engagement. While all seven predictor scales were significantly associated with patient advocacy engagement in correlational analyses, only Eagerness, Skills, and Belief the Hospital Empowers Patients predicted patient advocacy engagement in regression analyses. Additionally, younger professionals engaged in higher levels of patient advocacy than older professionals, and social workers engaged in greater patient advocacy than nurses. Limitations and the utility of these findings for acute-care hospitals are discussed.
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Affiliation(s)
- Bruce S Jansson
- a School of Social Work , University of Southern California , Los Angeles , California , USA
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Abstract
This article offers health care chaplains a pastoral response to moral distress experienced by health care professionals. The article offers a broad definition, explores its impact on health care professionals, and looks at various interventions to ameliorate its effects. The article goes on to clarify the concept of moral distress by differentiating it from the experience of moral dilemmas, and looking closer at the aspects of initial and reactive distress. After defining moral distress, the article explores two clinical models that create a better context to understand the phenomenon. Finally, the article proposes a pastoral response to moral distress from the integration of the five functions of pastoral care: "healing," "sustaining," "guiding," "reconciling," and "nurturing" based on the work of William Clebsch, Charles Jaekle, and Howard Clinebell. The author then applies the pastoral response to moral distress by illustrating the outcome of a scenario with a critical care nurse.
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Affiliation(s)
- Michael Guthrie
- a Spiritual Care Department , Presbyterian St. Luke's Medical Center, Rocky Mountain Hospital for Children , Denver , Colorado , USA
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Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs 2014; 23:33-41. [PMID: 23320816 DOI: 10.1111/inm.12000] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2012] [Indexed: 12/01/2022]
Abstract
Moral distress has received much attention in international nursing published work in recent years. However, in the published work, little is known about the moral distress of mental health nurses. The aims of this study were to examine the intensity level of moral distress, to identify the best predictors of moral distress, and to examine relationships of moral distress with burnout, job satisfaction, intention to leave the current job, and both demographic and work-related variables of that group. Employing a descriptive correlational cross-section design and a convenience sampling method, data were collected using the Moral Distress Scale for Psychiatric Nurses, Maslach Burnout Inventory, and Job Satisfaction Scale from 130 Jordanian mental health nurses working in the largest psychiatric hospital in Jordan. Results showed that the intensity level of moral distress was found to be moderately high, especially in an 'unethical conduct by caregivers' subscale. Age, income level, nurses' years of experience, and caseloads correlated significantly and negatively with moral distress, while educational level and intention to leave the current job correlated significantly and positively with moral distress. Interestingly, job satisfaction did not significantly correlate with moral distress. Income level, caseloads, burnout level, attending workshops in mental health, and educational level were the best predictors of moral distress. More studies on moral distress and continuing educational interventional programs aimed at minimizing the levels of moral distress and burnout at institutional and individual level are required.
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Affiliation(s)
- Shaher H Hamaideh
- Community and Mental Health Nursing Department, Faculty of Nursing, The Hashemite University, Zarka, Jordan; AlMaarefa College, Riyadh, Saudi Arabia
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Josse-Eklund A, Jossebo M, Sandin-Bojö AK, Wilde-Larsson B, Petzäll K. Swedish nurses' perceptions of influencers on patient advocacy: a phenomenographic study. Nurs Ethics 2014; 21:673-83. [PMID: 24477259 DOI: 10.1177/0969733013515488] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A limited number of studies have shown that patient advocacy can be influenced by both facilitators and barriers which can encourage and discourage nurses to act as patient advocates. OBJECTIVE This study's aim was to describe Swedish nurses' perceptions of influencers on patient advocacy. RESEARCH DESIGN AND CONTEXT Interviews with 18 registered nurses from different Swedish clinical contexts were analysed using the phenomenographic method. ETHICAL CONSIDERATIONS Ethical revisions were made in accordance with national legislation and guidelines by committees for research ethics at Karlstad University. FINDINGS Three levels of hierarchically related influencers on patient advocacy were found in the descriptive categories. The fundamental influencer, the nurse's character traits, was described in the perceptions that advocacy is influenced by nurse's having a moral compass, having control over the care situation, being protective and feeling secure as a nurse. The second most vital influencer, the nurse's bond with the patient, was expressed in the perceptions of knowing the patient and feeling empathy for the patient. The third level of influencers, the organisational conditions, was described in the perceptions that the organisational structures and organisational culture influence patient advocacy. DISCUSSION The results correspond with findings from earlier research but add an understanding that influencers on patient advocacy exist at three hierarchically related levels. CONCLUSION The nurse's character traits are the fundamental influencer to patient advocacy, but in order to be comfortable and secure when advocating for patients, nurses also need to be familiar with both the patient and the situation. A supposition could be that all influencers interact, which needs to be further addressed in future studies.
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Affiliation(s)
| | | | | | | | - Kerstin Petzäll
- Karlstad University, Sweden; Gjøvik University College, Norway
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A personal reflection: the difficult decision to leave critical care nursing. Dimens Crit Care Nurs 2013; 31:330-5. [PMID: 23042467 DOI: 10.1097/dcc.0b013e31826bc78c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
At some point in their careers, all critical care nurses will decide that it is time for them to leave critical care nursing. Whether this decision happens because of role change, retirement, or burnout, the decision can be a difficult one. This article explains my decision to leave the pediatric critical care unit and explores some of the reasons nurses leave critical care.
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A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace. ACTA ACUST UNITED AC 2013. [DOI: 10.1017/orp.2013.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite the importance of moral distress in the nursing scholarship, little attention is paid to the phenomena in the psychological literature as an important occupational stressor. A factor limiting the application of moral distress to other occupational settings is its definitional features. First, a necessary condition of moral distress is the acknowledgment prior to behaviour initiation that behaviour will contravene personal moral ideals. Second, the definition of moral distress specifies that the inability to act in accordance with one's moral framework is driven by institutional constraints (non-autonomous behaviour). This article proposes that moral distress not be limited in these ways, and makes two central contributions to resolve this core problem. We offer a critique and extension of the conceptual definition of moral distress. Fourteen Australian medical doctors participated in a semi-structured interview regarding occupational morally distressing events. Medical doctors were chosen for our interviews because they are an occupational population with considerable decision-making autonomy. Based on the findings, two recommendations are made: (1) that the definition of moral distress is not limited to events where decision-making and behaviour is non-autonomous, and (2) moral distress should not be limited to occasions where the moral conflict is identified prior to decision-making or behaviour. An alternative definition of moral distress is proposed. We conclude that while organisational limitations are an important precipitate of moral distress, they are not a necessary condition for its emergence.
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Abstract
Nurses are frequently confronted with ethical dilemmas in their nursing practice. As a consequence, nurses report experiencing moral distress. The aim of this review was to synthesize the available quantitative evidence in the literature on moral distress experienced by nurses. We appraised 19 articles published between January 1984 and December 2011. This review revealed that many nurses experience moral distress associated with difficult care situations and feel burnout, which can have an impact on their professional position. Further research is required to examine worksite strategies to support nurses in these situations and to develop coping strategies for dealing with moral distress.
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Reiger K, Lane K. ‘How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites. Women Birth 2013; 26:133-7. [DOI: 10.1016/j.wombi.2012.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 11/08/2012] [Accepted: 11/13/2012] [Indexed: 11/29/2022]
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Browning AM. CNE article: moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care 2013; 22:143-51. [PMID: 23455864 DOI: 10.4037/ajcc2013437] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Critical care nurses providing care for adults at the end of life may encounter moral distress when they cannot do what they believe is ethically correct. Psychological empowerment can decrease moral distress among critical care nurses. OBJECTIVES To describe the relationships between moral distress, psychological empowerment, and demographics in critical care nurses caring for patients at the end of life. METHOD A total of 277 critical care nurses were surveyed via the Moral Distress Scale and the Psychological Empowerment Instrument. Responses were scored on a Likert scale of 1 to 7. RESULTS Moral distress intensity was high (mean 5.34, SD 1.32) and positively correlated with age (r = 0.179, P = .01). Moral distress frequency was moderate (mean 2.51, SD 0.87) and negatively correlated with nurses' collaboration in end-of-life patient care conferences (r = -0.191, P = .007). Psychological empowerment scores (mean 5.31, SD 1.00) were high and positively correlated with age (r = 0.139, P = .03), years of experience (r = 0.165, P = .01), collaboration in end-of-life-care conferences (r = 0.163, P = .01), and end-of-life-care education (r = 0.221, P = .001) and were negatively correlated with moral distress frequency (r = -0.194, P = .01). Multiple regression analysis revealed that empowerment was a significant predictor of moral distress frequency (â = .222, P < .01). CONCLUSION The significant negative correlation between psychological empowerment and frequency of moral distress in these nurses indicated that nurses with higher perceived empowerment experience moral distress less often. This finding is of particular interest as interventions to decrease moral distress are sought.
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Affiliation(s)
- Annette M. Browning
- Annette M. Browning is an associate professor of nursing and director of simulation learning at Biola University, La Mirada, California
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A Pilot Study Examining Moral Distress in Nurses Working in One United States Burn Center. J Burn Care Res 2013; 34:521-8. [DOI: 10.1097/bcr.0b013e31828c7397] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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