Moral distress revisited: the viewpoints and responses of nurses

Experiences and support of Australian nurses who identify as a second victim: A mixed methods study

AIMS

In this study, researchers investigated experiences and key elements of effective support programs that promote recovery in nurses who identify as second victims in Australia.

DESIGN

Sequential explanatory mixed methods investigated experiences of nurses who identify as second victims, including support received and any educational and training included.

METHODS

Data were collected using survey and in-depth interviews. Survey data were analysed using descriptive and non-parametric testing and thematic analysis was used to analyse qualitative data.

RESULTS

Forty-three nurses indicated involvement in a patient safety incident in the previous five years with 27 nurses completing the survey. Thirty-seven percent reported experiencing psychological distress and 33% physical symptoms. Only 4% reported experiencing weak colleague support while 22% reported poor supervisor and 56% poor organisational support. Qualitative data from seven interviews revealed five themes identified included the Education and training; Environment surrounding the event; Burden of reporting; a 'You've just got to get on with it' culture; and Ways to action positive change.

CONCLUSION

Empathy and support from trained peer support colleagues were key elements to recovery of nurses who identified as second victims. The role of culture, and family values and beliefs in support of second victims need further investigation. Support programs need to address, not only psychological consequences of a patient safety event on the nurse, but also physical ramifications. Support of supervisors and organisations following a patient safety event may facilitate retention of nurses. The role of education and training in support programs requires further investigation.

Validation of the reduced version of the Brazilian Scale of Moral Distress in Nurses

OBJECTIVE

to validate a model of the reduced version of the Brazilian Scale of Moral Distress in Nurses.

METHOD

methodological study, with a sample of 269 nurses from a public university hospital in southern Brazil. A sociodemographic questionnaire and the Brazilian Moral Distress Scale for Nurses were used. Descriptive statistics, structural equation modeling, and invariance analysis between age groups were used.

RESULTS

regarding profile, professionals aged between 31 and 40, women, married, and specialists prevailed. The structural model fitted the data with acceptable fit indices. The proposed model showed excellent internal consistency, convergent validity, and discriminant validity. The analysis of the structural model revealed that the five hypotheses were confirmed, and the invariance between the age groups indicates that the way the variables are conceptualized, measured, and interrelated in the model does not affect the results, regardless of the groups compared.

CONCLUSION

the scale achieved satisfactory psychometric indicators, proving to be suitable for use, maintaining the relevant validation elements per dimension, and offering practical advantages. Further research is suggested to deepen our understanding of the consequences of moral distress and to develop effective strategies for managing it.

BACKGROUND

(1)The reduced version of the EDME-BR consisted of 24 questions and six factors. (2)Analysis of invariance and structural equation modeling were used for validation. (3)Internal consistency and composite reliability values were adequate. (4)The tests indicated sufficient predictive relevance of the proposed model. (5)The reduced scale offers a clear, accessible approach with a shorter response time.

Exploring Moral Distress, Related Factors and Coping in Emergency Nurses: A Mixed Method Study

AIM

To determine emergency nurses with moral distress level, related factors and coping.

DESIGN

This is a mixed-methods study which included quantitative and qualitative approaches.

METHODS

In quantitative phase, surveys were completed to 252 emergency nurses, while in the qualitative phase, semi-structured interviews were conducted with 23 nurses. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data.

RESULTS

The related factors of moral distress in nurses were as follows; educational status, work experience, satisfaction, and employment status. EN usually uses positive reinterpretation and development to cope with problems and tried to solve moral distress by getting own individual solutions and getting support from colleagues, friends and families due to lack of support from managers. In order to improve healthy working environment and conditions, it is important to create plans and strategies for EDs. It is recommended to develop practical and structural strategies and interventions that effective coping with moral distress by hospital managers.

PATIENT OR PUBLIC CONTRIBUTION

It will increase the quality of care provided by nurses and patient satisfaction.

Strategies to mitigate moral distress as reported by eldercare professionals

Eldercare workers experience higher levels of moral distress than other health and social care service workers. Moral distress is a psychological response to a morally challenging event. Very little is known about moral distress in the context of eldercare and about the mechanisms of preventing or mitigating moral distress. This qualitative study was conducted as part of the "Ensuring the availability of staff and the attractiveness of the sector in eldercareservices" project in Finland in 2021. The data were from 39 semi-structured interviews. This qualitative interview data were examined using two-stage content analysis. The key finding of this study, as reported by eldercare professionals, is that strategies to mitigate moral distress can be found at all organizational levels : organizational, workplace and individual. The tools that emerged from the interviews fell into four main categories:) organizational support and education 2) peer support 3) improving self-care and competence and 4) defending patients. The main identified categories confirmed the earlier findings but the qualitative, rich research interview data provided new insights into a little-studied topic: mitigating moral distress in eldercare. The main conclusion is that, in order to mitigate moral distress, ethical competence needs to be strengthened at all organizational levels.

Characteristics of moral distress from nurses' perspectives: An integrative review

Objective

This integrative review aimed to identify the common characteristics of moral distress in nursing and distinguish it from other types of distress by examining nurses' perspectives in the literature. These insights will help update existing tools and create new ones to capture moral distress better, guiding the development and implementation of strategies to support nurses in addressing this challenge.

Methods

Whittemore and Knafl's integrative review method was employed to guide a systematic search for literature in three databases (EBSCO Medline, CINAHL, and PubMed). Additionally, two journals, Bioethics and Nursing Ethics, were manually searched to reduce search bias. The included studies were primary resources published in English between 2018 and 2023, utilizing quantitative, qualitative, or mixed methods to examine moral distress's characteristics, components, and definitions. All of identified studies were screened, extracted, and analyzed independently by two researchers.

Results

Nineteen studies were included. The results were grouped into five themes shaping the main characteristics of moral distress: 1) experiencing a moral situation, with five ethically conflicted situations identified, including treatment plans, professional and personal moral values, team dynamics, complex contexts, clinical practices, and patient-centered care; 2) making a moral judgment, where nurses experience moral distress when they cannot act consistently with their values, ethical principles, and moral duties; 3) the presence of constraints, categorized at three levels: individual factors related to the nurse, patient, and patient's family; team factors related to the team or unit involved; and system factors, including institutional and policy elements; 4) moral wrongdoing, which occurs when nurses are unable to perform the right moral action; and 5) moral suffering, with studies showing that moral distress impacts physical, emotional, and psychological well-being.

Conclusion

The findings enhance the understanding of moral distress characteristics among nursing staff, highlighting the concept of the crescendo effect, which underscores the cumulative and escalating nature of unresolved moral distress, emphasizing the need to address moral conflicts proactively to prevent the erosion of moral integrity and professional satisfaction.

Assessment of nurses' workplace silence behaviour motives: A cross-sectional study

Objectives

The motives that lead to nurses' workplace silence behaviour are essential to understand, as the failure to voice their concerns and maintain silence may cause various adverse outcomes, including burnout, turnover, job dissatisfaction, low productivity, and mental and moral distress. This study aimed to identify the level and influencing motives of the workplace silence behaviour among nurses at the National Guard Hospital in Madinah.

Methods

A descriptive cross-sectional survey was conducted in January and February 2023. The participants completed a questionnaire with two parts: the sociodemographic data form and the Workplace Silence Behavior Nursing Motives Scale. Data analysis was performed by descriptive statistics and the chi-square test.

Results

The overall level for all workplace silence behavior motives is moderate (3.29 ± 0.69), with Avoidance Motives dimension receiving the highest scores (3.62 ± 0.75) and Organization-Oriented Motives dimension receiving the lowest (3.15 ± 0.86). Chi-square test showed that Saudi nationality (χ 2  = 0.015, P = 0.019) and monthly income (χ 2  = 0.045, P = 0.013) are factors in high-moderate levels of silence behaviour.

Conclusions

The overall level of workplace silence behaviour motives was found to be moderate, nurses have higher monthly salaries and non-Saudi nationals tend to have higher levels of workplace silence behaviour motives. The study results provide a reference for nursing managers to pay attention to nurses' workplace silence behavior and take corresponding intervention measures.

Development of burnout and moral distress in intensive care nurses: An integrative literature review

AIMS

To describe, through an integrative literature review, the factors contributing to the development of burnout and moral distress in nursing professionals working in intensive care units and to identify the assessment tools used most frequently to assess burnout and moral distress.

METHODS

An integrative literature review was carried out. PubMed, CINAHL, PsycINFO, SciELO, Dialnet, Web of Science, Scopus, and Cochrane databases were reviewed from January 2012 to February 2023. Additionally, snowball sampling was used. The results were analysed by using integrative synthesis, as proposed by Whittemore et al., the Critical Appraisal Skills Programme for literature reviews, the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for quantitative observational studies, and the Joanna Briggs Institute checklist for qualitative research were used to evaluate evidence quality.

RESULTS

Forty-one articles were selected for review: 36 were cross-sectional descriptive articles, and five were literature reviews. The articles were grouped into five-factor categories: 1) personal factors, 2) organisational factors, 3) labour relations factors, 4) end-of-life care factors, and 5) factors related to coronavirus disease 2019 (COVID-19). The Maslach Burnout Inventory-Human Services Survey and the Moral Distress Survey-Revised instruments were the most commonly used to measure burnout and moral distress.

CONCLUSIONS

This review highlights the multiple personal, organisational, relational, situational, and end-of-life factors promoting burnout and moral distress among critical care nurses. Interventions in these areas are necessary to achieve nurses' job satisfaction and retention while improving nurses' quality of care.

Exploring the moderating role of health-promoting behaviours and self-compassion on the relationship between clinical decision-making and nurses' well-being

Background

Clinical decision-making is an essential part of the nursing role and has implications for both patient care and nurses' well-being.

Aim

This study aimed to explore the relationship between nurses' perceptions of clinical decision-making ability and moral distress across a nursing population, and the potential link to self-compassion and health-promoting behaviours.

Methods

A self-report questionnaire was distributed to a sample of nurses (N = 152) from April to September 2022. The survey explored nurses' perceptions of clinical decision-making ability, moral distress, physical activity, grazing, stress-eating, burnout and self-compassion.

Results

Perceived clinical decision-making ability was associated with moral distress experience, and both self-compassion and grazing moderated this relationship, independently.

Conclusion

Findings highlight the link between nurses' perceptions of clinical decision-making ability and moral distress experience. Both eating behaviours and self-compassion influence the relationship between these two factors and identify potential areas that may support (and hinder) nurses' well-being through clinical decision-making. These findings reinforce the importance of healthy eating habits and being self-compassionate to prevent moral distress arising as a result of clinical decision-making.

The Effect of Nursing Moral Distress on Intent to Leave Employment

OBJECTIVE

This study explored the impact of moral distress (MD) and respondent characteristics on intent to leave employment.

BACKGROUND

Managing patient care, within organizational constraints, may create physical discomfort or mental peace disturbances such as MD, negatively impacting RN retention.

METHODS

Responses from 948 RNs were collected using an anonymous online survey. The impact of MD on intent to leave employment was explored.

RESULTS

MD was significantly higher among RNs intending to leave employment. System-level and team-level integrity attributes were significant factors predicting intent to leave, controlling for potential confounders. The odds of intending to leave were 147% higher for new graduate RNs, 124% higher for direct care RNs, and 63% higher for 2nd-career RNs. Gender and race were not significant predictors.

CONCLUSION

Exploring root causes contributing to MD frequency and severity is critical to maintain a healthy work environment. Mitigating MD in the work environment may enhance nursing practice and improve patient care. Support for new graduate and 2nd-career RNs can be realized, further reducing turnover for these vulnerable populations of the nursing workforce.

Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations

In pediatric critical care, nurses are the primary caregivers for critically ill children and are particularly vulnerable to moral distress. There is limited evidence on what approaches are effective to minimize moral distress among these nurses. To identify intervention attributes that critical care nurses with moral distress histories deem important to develop a moral distress intervention. We used a qualitative description approach. Participants were recruited using purposive sampling between October 2020 to May 2021 from pediatric critical care units in a western Canadian province. We conducted individual semi-structured interviews via Zoom. A total of 10 registered nurses participated in the study. Four main themes were identified: (1) "I'm sorry, there's nothing else": increasing supports for patients and families; (2) "someone will commit suicide": improving supports for nurses: (3) "Everyone needs to be heard": improving patient care communication; and (4) "I didn't see it coming": providing education to mitigate moral distress. Most participants stated they wanted an intervention to improve communication among the healthcare team and noted changes to unit practices that could decrease moral distress. This is the first study that asks nurses what is needed to minimize their moral distress. Although there are multiple strategies in place to help nurses with difficult aspects of their work, additional strategies are needed to help nurses experiencing moral distress. Moving the research focus from identifying moral distress towards developing effective interventions is needed. Identifying what nurses need is critical to develop effective moral distress interventions.

Ethical issues experienced by nurses during COVID-19 pandemic: Systematic review

BACKGROUND

Frontline nurses who care for patients with COVID-19 work in stressful environments, and many inevitably struggle with unanticipated ethical issues. Little is known about the unique, ethically sensitive issues that nurses faced when caring for patients with COVID-19.

AIM

To better understand how frontline nurses who care for patients with COVID-19 experience ethical issues towards others and themselves.

METHODS

Systematic review of qualitative evidence carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses on ethical literature (PRISMA-Ethics). The electronic databases PubMed, Embase, Cinahl, Web of Science, Philosopher's Index, and Scopus were queried to identify candidate articles. Articles appearing from March 1, 2020 to December 31, 2022 were considered if they met the following inclusion criteria: (1) Published qualitative and mixed method studies and (2) ethical issues experienced by nurses caring for patients with COVID-19. We appraised the quality of included studies, and data analysis was guided by QUAGOL principles.

FINDINGS

Twenty-six studies meeting our inclusion criteria for how nurses experience ethical issues were characterised by two key themes: (1) the moral character of nurses as a willingness to respond to the vulnerability of human beings and (2) ethical issues nurses acted as barriers sometimes, impeding them from responding to requests of vulnerable human beings for dignified care.

CONCLUSION

Our review provides a deeper understanding of nurses' experiences of ethically sensitive issues, while also highlighting the critical need for adjustments to be made at organisational and societal levels. Ethical issues that emerged in situations where organisational and situational constraints impeded nurses' ethical responses to patients' appeals suggests that early practical support should be made available to resolve ethical issues recognised by nurses. Such support contributes to protecting and promoting not only the dignity of patients with COVID-19 but also of fellow humans in need during crisis.

Nurses' experiences of moral distress and how it affects daily work in surgical care-a qualitative study

AIM

To describe nurses' and specialist nurses' experiences of moral distress and how it affects daily work in surgical care.

DESIGN

A qualitative descriptive study design was used.

METHODS

A qualitative study with 12 interviews with nurses and specialist nurses working in surgical care. All interviews were conducted during October and November 2022 in two hospitals in southeastern Sweden. Data were analysed using conventional qualitative content analysis.

FINDINGS

Three categories and seven subcategories generated from the data analysis. The three categories generated from the analysis were Experiences that lead to moral distress, Perceived consequences of moral distress and Strategies in case of moral distress. The results show that a lack of personnel in combination with people with complex surgical needs is the main source of moral distress. Both high demands on nurses as individuals and the teamwork are factors that generate moral distress and can have severe consequences for the safety of patients, individual nurses and future care.

CONCLUSIONS

The results show that moral distress is a problem for today's nurses and specialist nurses in surgical care. Action is necessary to prevent nurses from leaving surgical care. Prioritizing tasks is perceived as challenging for the profession, and moral distress can pose a patient safety risk.

IMPACT

Surgical care departments should design support structures for nurses, give nurses an authentic voice to express ethical concerns and allow them to practice surgical nursing in a way that does not violate their core professional values. Healthcare organizations should take this seriously and work strategically to make the nursing profession more attractive.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

Inductive process of moral distress development in viewpoints from surgical nurses: a mixed-method study

BACKGROUND

Moral distress is a multifactorial and complex phenomenon influenced by various individual, cultural, and systemic factors. This study aimed to investigate the frequency and intensity of nurses' moral distress, explore their experiences, and develop the conceptual model of risk factors of moral distress in surgical units and operating rooms.

METHOD

This is a sequential mixed-method study conducted at four teaching hospitals affiliated with the Qom University of Medical Sciences. In the first step, the moral distress of nurses in surgical units and operating rooms was investigated by a survey. The participants included nurses who worked in the operating room and surgical units. (n = 180). The data was collected by a Moral Distress Scale-Revised (MDS-R) questionnaire. In the second step, the experiences of nurses regarding risk factors of moral distress were explored using semi-structured interviews and analyzed using the conventional content analysis by Graneheim and Lundman's approach.

RESULTS

One hundred eighty nurses participated in this study. The mean total moral distress scores ranged from 12 to 221, with a mean (SD) of 116.8 (42.73). The causes of moral distress cited with the highest frequency and intensity related to the 'role of healthcare providers'. The experiences of the participants in the theme 'Inductive process of moral distress development' were categorized into three categories: 'Melting into the faulty system', 'Power and the system as distress promotors', and 'Perceived unpleasant consequences'.

CONCLUSION

The results indicated that the frequency of moral distress in operating rooms and surgical units was at a moderate level and the distress intensity of nurses was at a moderately high level. The results indicated that in the investigated system, the "inductive moral process of distress development" was continuously understood by the participants. This process was influenced by systemic and individual factors. Weak assertiveness, conservative compromise, and desensitization to unprofessionalism as individual factors were effective in causing distress. Risk factors at the systemic level led nurses to melt into the faulty system and created adverse outcomes at the individual level. The lack of systemic support and the stabilization of mobbing by powerful system members had a negative impact on the individual factors of distress development. Also, these factors directly cause negative consequences.

The Impact of Moral Distress on Staff and Novice Nurses

ABSTRACT

Moral distress is an interior affliction associated with exterior conflicts between one's values, obligations, and actions. This article builds understanding of moral distress among nurses and the importance of reducing its harmful impact, particularly to novice nurses. Moral distress is defined along with ethical issues and concepts related to moral distress, its current impact, coping with moral distress and building moral reserve, and the significance of acting according to one's conscience.

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed-methods systematic review and thematic synthesis

AIM

To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well-being and professional and career intentions.

DESIGN

Joanna Briggs Institute mixed-methods systematic review and thematic synthesis. Registered in Prospero (Redacted).

METHODS

Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction.

RESULTS

Searches yielded 2343 hits. Seventy-seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well-being.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Elderly Care Practitioners' Perceptions of Moral Distress in the Work Development Discussions

Elderly care practitioners are at specific risk of experiencing prolonged moral distress, which is associated with occupational health-related problems, low job satisfaction, and staff turnover. So far, little attention has been paid to the moral concerns specific to elderly care, a field whose importance is constantly growing as the populations in Western countries age. By drawing on seven workshop conversations as data and interaction-oriented focus group research, conversation analysis and discursive psychology as methods, we aim to study the ways in which elderly care practitioners discuss moral distress in their work. We found that the moral distress experienced was related to three topics that arose when client work and teamwork contexts were discussed: the power to influence, equal treatment of people, and collaboration. The interaction in client work and teamwork contexts differed systematically. The discussion on client work was characterised by negotiations on the rights and wrongs of care work, whereas the teamwork discussion engendered emotional outbursts, a potential manifestation of work-related burnout. Hence, attempts to improve the work-related health of elderly care practitioners require time and space for sharing the emotional load, followed by reflection on what could be improved in the work and what institutional solutions could help in morally distressing situations.

Moral distress, moral courage, and career identity among nurses: A cross-sectional study

Background

The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity.

Objectives

To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral distress and career identity among nurses.

Design

A quantitative, cross-sectional study.

Methods

A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses’ Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement.

Ethical consideration

Research ethics approval was obtained from the researcher’s university and hospital where this study was conducted prior to data collection.

Findings

Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity ( β = −0.230 to −0.163, p < 0.01).

Discussion

The findings reveal a relationship between moral distress, moral courage, and career identity among nurses.

Conclusion

By paying attention to nurses’ moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses.

Community healthcare workers' experiences during and after COVID-19 lockdown: A qualitative study from Aotearoa New Zealand

Shortly after the COVID-19 pandemic reached Aotearoa New Zealand, stringent lockdown measures lasting 7 weeks were introduced to manage community spread of the virus. This paper reports the findings of a qualitative study examining how lockdown measures impacted upon the lives of nurses, midwives and personal care assistants caring for community-based patients during this time. The study involved nationwide surveys and in-depth interviews with 15 registered nurses employed in community settings, two community midwives and five personal care assistants. During the lockdown, nurses, midwives and personal care assistants working in the community showed considerable courage in answering their 'call to duty' by taking on heightened care responsibilities and going 'the extra mile' to help others. They faced significant risks to personal and professional relationships when they were required to take on additional and complex responsibilities for community-based patients. Despite the hypervigilant monitoring of their personal protective equipment (PPE), the need to safeguard family and community members generated considerable stress and anxiety. Many also faced personal isolation and loneliness as a result of lockdown restrictions. Moreover, the negative impacts of experiences during lockdown often continued to be felt once restrictions had been lifted, inflecting life during periods in which community transmission of COVID-19 was not occurring. This article makes five core service delivery and policy recommendations for supporting community-based nurses, midwives and personal care assistants in respiratory disease pandemics: acknowledging the crucial role played by community-based carers and the associated stress and anxiety they endured by championing respect and compassion; demystifying the 'heroism' or 'self-sacrifice' projected onto care workers; the timely provision of adequate protective equipment; improving remuneration, with adequate provision for time off; and regular counselling, peer support groups and education on work-life balance delivered by support workers in recognition of stressors arising from these complex and isolated working conditions.

Moral distress in critical care nursing practice: A concept analysis

AIM

To provide a critical analysis of the concept of moral distress (MD) in critical care (CC) nursing.

BACKGROUND

Despite extensive inquiry pertaining to the legitimacy of MD within nursing discourse, some authors still question its relevancy to the profession. However, amid the global COVID-19 pandemic, MD is generating a significant amount of discussion anew, warranting the further exploration of the concept within CC nursing to provide clarity and expand on the definition.

DESIGN

Rodger's Evolutionary Concept Analysis method was used to guide this analysis.

METHODS

Related terms, attributes, antecedents, and consequences of MD were identified using current literature.

RESULTS

The results of this analysis demonstrate strong congruence between the attributes, antecedents, and negative consequences pertaining to MD. However, a new theme has emerged from this review of the contemporary literature, highlighting the potential unexpected positive outcomes perceived by nurses who experience MD, including the provision of better care, increased levels of empathy, and enhanced opportunities for ethical reflection.

Moral distress and moral resilience of nurse managers

BACKGROUND

Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience.

AIM

The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil.

RESEARCH DESIGN

The research design is the qualitative study with discursive textual analysis.

PARTICIPANTS AND RESEARCH CONTEXT

: 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions.

ETHICAL CONSIDERATIONS

The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity.

FINDINGS

Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation.

CONCLUSION

From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience.

Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders

Background

Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges.

Methods

Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis.

Results

We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate.

Conclusion

The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00456-y.

Effects of an ethics education program on nurses' moral efficacy in an acute health-care facility

AIM

This study aimed to evaluate an ethics education program developed to increase moral efficacy among nurses in an acute health-care facility.

BACKGROUND

Moral distress among nurses can cause serious problems in terms of hospital organizations and patient safety. To reduce moral distress and promote professional confidence in nursing practice, a strategic intervention program is needed.

METHODS

An ethics education program introduced methods to increase self-efficacy in accordance with Bandura's social cognitive theory. Eight nurses were recruited from 2017 to 2019 and all conversations and discussions regarding the ethics consultation were recorded on IC recorders and analyzed qualitatively.

RESULTS

Four core categories-Convinced to take an active role in ethical issues; Progressed in nursing practice with ethical agency; Experienced professional transformation; and Empowered by the presence of colleagues-emerged as outcomes of the ethics education program that related to moral efficacy.

CONCLUSIONS

The four core outcome categories suggested that the participants had gained confidence after taking part in the ethical education program.

IMPLICATIONS FOR NURSING MANAGEMENT

The results of the participants' described behaviors and actions suggested that they would be proactive in contributing to reductions in moral distress in the future.

Moral distress interventions: An integrative literature review

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

STRATEGIES FOR COPING WITH MORAL DISTRESS ADOPTED BY NURSES IN TERTIARY CARE: A SCOPING REVIEW

ABSTRACT Objective: to map the scientific evidence on strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care. Method: this is a Scoping Review based on the PRISMA-ScR recommendations. The searches were performed in September 2020 in the MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane and Biblioteca Virtual en Saúde databases. The eligibility criterion was to include studies that discussed strategies for coping with moral distress adopted by nurses in tertiary care, finding 2,041 studies, which were organized and screened in the Endnote software. The data were organized in Excel spreadsheets and analysis of the results was performed using the ATLAS.ti software. Results: the final selected sample consisted of 23 studies, which were grouped in two axes: strategies and recommendations. Four articles were included in the “strategies” axis, which reported actions taken to face moral distress, detailing the intervention and their results. The others, included in the “recommendations” axis, are articles whose focus was the experience of moral distress, suggesting important aspects to face it. Conclusion: recognition of moral distress by nurses and the opportunity for collective discussion and exchange of experiences are ways of collectively facing the situations. In addition, the institution's active participation in carrying out interventions was recommended. However, gaps were noticed in the production of studies that actually go deeper into intervention actions to cope with moral distress.

The association between moral distress and mental health among nurses working at selected hospitals in Iran during the COVID-19 pandemic

BACKGROUND

In the event of an epidemic outbreak, the mental health of medical staff, including nurses who serve on the frontlines of hospitals, can be affected; thus, the identification of factors affecting nurses' mental health is of importance.

OBJECTIVE

This study aimed to examine the association between moral distress and the mental health of nurses working at four selected hospitals in Iran during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A cross-sectional questionnaire survey was conducted on 296 nurses working at the selected hospitals in Bushehr and Shiraz (south of Iran) at the time of the COVID-19 outbreak. The collected data were analyzed via logistic regression analysis.

RESULTS

The mean scores for nurses' moral distress were low (54.31±24.84). The results of this study indicated more symptoms of mental issues among nurses (73.60%). Moreover, a significant association was observed between mental health and moral distress. Among the examined demographic variables, only gender had a significant association with mental health (p-value = 0.014).

CONCLUSION

The results of this study indicated that an increase in moral distress would lead to a significant increase in mental health issues of the examined nurses. Nurse managers and hospital policymakers should develop strategies to enhance nurses' level of mental health, as well as providing adequate emotional and family support for nurses. Considering the intensifying role of gender in this association, timely interventions are necessary to reduce the negative effects of workplace pressure/stress on female nurses.

Healthcare in Ghana amidst the coronavirus pandemic: a narrative literature review

The Coronavirus pandemic has caused more deaths than any other single disease since the outbreak was confirmed. The World Health Organization in collaboration with national and international health agencies continues to lead the way in bracing global healthcare systems to fight the pandemic. There are variations in national capacities towards the preparedness and management of the pandemic. The Government of Ghana, through the Ministry of Health and Ghana Health Service, continues to provide policy and operational directions towards the containment of the pandemic. The purpose of this study is to review the setup of the healthcare sector in Ghana in light of the ongoing pandemic. This study is a narrative literature review in which data was extracted from electronic databases such as PubMed, Google Scholar, Scopus and Ebscohost that published Covid-19 research articles from Ghana. Literature was analyzed and discussed based on the structures and systems available in the healthcare sector, as well as trends available from the global perspective. The healthcare sector in Ghana continues to support the citizenry in the wake of the Coronavirus pandemic. The government provides regular updates and continue to pledge their support in dealing with the effects of the pandemic. Challenges with accessibility, workforce, funding, and infrastructure remain the major hindrances in fighting the pandemic. The government and healthcare partners need to continually reform the healthcare system to meet the increasing demand for healthcare during the pandemic.

Nursing practice environment and employee silence about patient safety: The mediating role of professional discrimination experienced by nurses

AIMS

To examine the associations between nurse work environment with nurses' silence about patient safety and the mediating effects of professional discrimination experienced by nurses.

DESIGN

Multicentre cross-sectional study.

METHODS

Between January and April 2019, 607 nurses and nursing assistants from seven hospitals in Greece assessed their clinical environment using the 'Practice Environment Scale of the Nursing Work Index Revised-PES-NWIR', and the silence about patient safety. The 'Experiences of Discrimination Index' was adapted to specifically address experienced discrimination based on the nursing profession. The PROCESS macros for SPSS were used to examine the above associations.

FINDINGS

Better nurse practice environment, with the exception of 'staffing and resource adequacy' dimension, was directly associated with less experienced professional discrimination, and directly and indirectly associated with less silence about patient safety, through the mediating role of professional discrimination experienced by nurses.

CONCLUSIONS

Silence about patient safety is dependent on the clinical work environment and may be a response of nurses to discrimination in the work context. Both an improvement in the nurse work environment and a decrease in professional discrimination would minimize silence about patient safety.

IMPACT

On many occasions, nurses are directly or indirectly discouraged from voicing their concerns about patient safety or are ignored when they do, leading to employee silence and decreasing the standard of care (Alingh et al., BMJ Quality & Safety, 2019, 28, 39; Pope, Journal of Change Management, 2019, 19, 45). Nurses' work-related determinants for silence are not clearly understood in the patient safety context. A favourably evaluated nurse practice environment is associated with less experienced professional discrimination and less silence about patient safety. To minimize silence about patient safety, both the nurse work environment and the experienced professional discrimination should be taken into consideration by nurse and healthcare managers.

Caring for an Unconscious Transgender Patient at the End of Life: Ethical Considerations and Implications

Individuals who identify as transgender (trans) or other gender-diverse identities are highly marginalized populations within the United States health care system. Transgender individuals experience a broad range of health disparities leading to devastating health outcomes. Experiences with discrimination and biased care often result in a lack of trust in providers and reduced care seeking, yet providers frequently rely on communication with trans patients to build competence. Consequently, when a trans patient has restricted communication, whether due to biological or psychological reasons, their care can be further disrupted. The nursing code of ethics compels the provision of competent care to all patients, regardless of demographics or gender identity, including individuals with serious illness and injury. This article describes an approach to the provision of affirmative, trans-inclusive care in a palliative nursing context that integrates cultural humility and self-reflection into an established patient care framework. The approach is then applied to identify ethical dilemmas present in the case of a trans patient who arrived at a hospital in an unconscious state following serious injury. Nurses' use of the ethical approach when caring for seriously ill trans patients would represent important progress toward fostering a health care system that provides affirmative, trans-inclusive care.

Validation of the Dutch-language version of Nurses' Moral Courage Scale

BACKGROUND

Moral courage as a part of nurses' moral competence has gained increasing interest as a means to strengthen nurses acting on their moral decisions and offering alleviation to their moral distress. To measure and assess nurses' moral courage, the development of culturally and internationally validated instruments is needed.

OBJECTIVE

The objective of this study was to validate the Dutch-language version of the four-component Nurses' Moral Courage Scale originally developed and validated in Finnish data.

RESEARCH DESIGN

This methodological study used non-experimental, cross-sectional exploratory design.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 559 nurses from two hospitals in Flanders, Belgium, completed the Dutch-language version of the Nurses' Moral Courage Scale.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed throughout the study. Permission to translate the Nurses' Moral Courage Scale was obtained from the copyright holder, and the ethical approval and permissions to conduct the study were obtained from the participating university and hospitals, respectively.

FINDINGS

The four-component 21-item, Dutch-language version of the Nurses' Moral Courage Scale proved to be valid and reliable as the original Finnish Nurses' Moral Courage Scale. The scale's internal consistency reliability was high (0.91) corresponding with the original Nurses' Moral Courage Scale validation study (0.93). The principal component analysis confirmed the four-component structure of the original Nurses' Moral Courage Scale to be valid also in the Belgian data explaining 58.1% of the variance. Confirmatory factor analysis based on goodness-of-fit indices provided evidence of the scale's construct validity. The use of a comparable sample of Belgian nurses working in speciality care settings as in the Finnish study supported the stability of the structure.

DISCUSSION AND CONCLUSION

The Dutch-language version of the Nurses' Moral Courage Scale is a reliable and valid instrument to measure nurses' self-assessed moral courage in speciality care nursing environments. Further validation studies in other countries, languages and nurse samples representing different healthcare environments would provide additional evidence of the scale's validity and initiatives for its further development.

Preserving nurses' professional dignity: Six evidence-based strategies

AIM

This study aimed to develop and refine strategies for preserving nurses' professional dignity.

BACKGROUND

Professional dignity is a non-negotiable nursing professional value. It should at all times be respected because of the worthiness of nurses as professional human beings. They are at the centre of healthcare societies. Their worth and contributions to the health of others should be acknowledged and preserved.

METHODS

Descriptive qualitative research was conducted during the development of the strategies while applying the principles of strategic navigation. The process was guided by the findings of the initial phase of the study and contextualised literature. Focus group discussions were held with healthcare professionals for the refinement of the strategies in two private hospitals in South Africa.

FINDINGS

The strategies unfolded multiple possibilities to value nurses' professional dignity. These were pathways for respecting, appreciating and supporting nurses; honouring nurses' desire to hold the well-being of patients in the highest regard; supporting nurses in fulfilling their professional roles; enabling nurses to take pride in themselves and the nursing profession; supporting nurses in demanding and complex circumstances and supporting nurses in coping with humiliating workplace experiences.

CONCLUSION

Strategies to ensure successful outcomes in preserving nurses' professional dignity were developed and refined. The professional dignity experiences that mattered most were presented.

IMPLICATIONS FOR NURSING/HEALTH POLICY

Valuing nurses' professional dignity promotes respect and support for nurses and their desire to prioritise patient-centred care, contributing to improved nursing practice and nurses' confidence to assert their professional dignity. Preserving nurses' professional dignity is a necessity in healthcare. It should be affirmed in equal standing in nursing codes of conduct, nursing curriculums and healthcare policies.

Nurses' self-assessed moral courage and related socio-demographic factors

BACKGROUND

Nurses need moral courage to ensure ethically good care. Moral courage is an individual characteristic and therefore it is relevant to examine its association with nurses' socio-demographic factors.

OBJECTIVE

To describe nurses' self-assessed level of moral courage and its association with their socio-demographic factors.

RESEARCH DESIGN

Quantitative descriptive cross-sectional study. The data were collected with Nurses' Moral Courage Scale and analyzed statistically.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 482 registered nurses from a major university hospital in Southern Finland completed the Finnish language version of Nurses' Moral Courage Scale in autumn 2017.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the university ethics committee and permission for the data collection from the participating hospital. Ethical principles and scientific guidelines were followed throughout the research process.

FINDINGS

Nurses' self-assessed level of moral courage was rather high. On Visual Analogy Scale (0-10), the mean value was 8.20 and the mean score of the four dimensional, 21-item Nurses' Moral Courage Scale was 4.09 on a 5-point Likert-type scale. Respondents' gender, present work role, ethical knowledge base, additional ethics education, self-study as a means to acquire ethical knowledge, and frequency of work situations needing moral courage were statistically significantly associated with nurses' moral courage.

DISCUSSION

Strongest association was found between nurses' higher moral courage level and formal and informal ethics education. Honesty and patient's humane and dignified encounter received the highest scores indicating respondents' internalization of the core values of nursing.

CONCLUSION

Although nurses were fairly morally courageous, moral courage should be a part of nurses' basic and continuing education thus covering its theoretical and practical learning. Since moral courage is a virtue that can be taught, learnt, and practiced, education is a relevant way to maintain and further strengthen nurses' moral courage.

Moral suffering in health professionals: portrait of the work environment in times of COVID-19

OBJECTIVE

To analyze potential triggers of moral suffering experiences of health professionals, reported in the media, during the COVID-19 pandemic and to propose a theoretical construct of analysis.

METHODS

Study with qualitative approach whose data source were 50 reports published online, collected passively and actively, submitted to Content Analysis with the help of ATLAS.ti software.

RESULTS

The potential moral problems that trigger moral suffering are related to the threat to moral integrity, infrastructure/logistics and teamwork problems, and emotional aspects, revealing their articulation with damage to the foundations of a healthy work environment, which generated the proposal of a construct.

FINAL CONSIDERATIONS

The articulation between the experiences of moral suffering and the commitment of the fundamentals of a healthy work environment has brought important contributions to the adoption of strategies to protect and stimulate moral deliberation by professionals in favor of practice and society.

Caring for victims of child maltreatment: Pediatric nurses' moral distress and burnout

BACKGROUND

Moral distress is a significant concern for nurses as it can lead to burnout and intentions to leave the profession. Pediatric nurses encounter stressful and ethically challenging situations when they care for suspected victims of child maltreatment. Data on pediatric nurses' moral distress are limited, as most research in this field has been done in adult inpatient and intensive care units.

AIM

The purpose of this study was to describe pediatric nurses' moral distress and evaluate the impact of caring for suspected victims of child maltreatment on nurses' moral distress, burnout, and intention to leave. Design and method: This descriptive cross-sectional correlational study was conducted in a mid-Atlantic, urban area Magnet pediatric level I trauma center that cares for over 1800 cases of suspected child maltreatment annually. An anonymous electronic survey was sent to all the nurses working at the hospital.

ETHICAL CONSIDERATIONS

Institutional Review Board approval was received from the first author's university and the hospital where the study was conducted.

FINDINGS

Overall, nurses (N = 146) reported low levels of moral distress with a mean score of 59.54 (SD = 49.22) and a range of 0-300 on the Moral Distress Scale Neonatal-Pediatric version. Although the frequency of caring for suspected child maltreatment victims did not affect nurses' moral distress, caring for victims with fatal maltreatment contributed to nurses' intention to leave, χ² (1) = 5.35, p = 0.02.

CONCLUSION

The results of this study add to the understanding of moral distress in pediatric nursing. Caring for victims with fatal maltreatment impacts pediatric nurses' intention to leave.

Nurses' moral distress in end-of-life care: A qualitative study

BACKGROUND

Moral distress is a neglected issue in most palliative education programmes, and research has largely focused on this phenomenon as an occupational problem for nursing staff.

RESEARCH QUESTION

The primary outcome of this study was to explore the causes of morally distressing events, feelings experienced by nurses and coping strategies utilised by a nursing population at an Italian teaching hospital. A secondary outcome of this qualitative study was to analyse whether palliative care or end-of-life care education may reduce morally distressing events.

RESEARCH DESIGN

A hermeneutic-phenomenological qualitative study was performed.

PARTICIPANTS AND RESEARCH CONTEXT

Participants were recruited through snowball sampling. The interviews were conducted and recorded by one interviewer and transcribed verbatim.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the Institutional Review Hospital Board.

FINDINGS

Six main themes emerged from the interview analyses: (1) the causes of moral distress; (2) feelings and emotions experienced during morally distressing events; (3) factors that affect the experience of moral distress; (4) strategies for coping with moral distress; (5) recovering from morally distressing events; and (6) end-of-life accompaniment. Varying opinions regarding the usefulness of palliative care education existed. Some nurses stated that participation in end-of-life courses did not help them cope with morally distressing events in the ward, and they believe that existing courses should be strengthened and better structured.

DISCUSSION

In this study, moral distress was often associated with poor communication or a lack of communication between healthcare professionals and the patients and/or their relatives and with the inability to satisfy the patients' last requests. According to our findings, the concept of 'good' end-of-life accompaniment was extremely important to our sample for the prevention of morally distressing events.

CONCLUSION

Nurses who work in the onco-haematological setting frequently experience moral distress. Determining the causes of moral distress at early stages is of paramount importance for finding a solution.

Moral reasoning as a catalyst for cultural competence and culturally responsive care

The importance of developing cultural competence among healthcare professionals is well recognized. However, the widespread reports of insensitivity and deficiencies in care for culturally diverse patients illuminate the need to review how cultural competence development is taught, learnt and applied in practice. Unless we can alter the 'hearts and minds' of practising nurses to provide the care that they know they should, culturally insensitive care will continue operating in subtle ways. This paper explores the ideas behind nurses' actions and omissions when caring for culturally diverse patients and proposes the need to examine cultural competence development through a moral reasoning lens. Examining cultural competence development through a moral reasoning lens can help empower nurses, whilst nurturing commitment and courage to providing quality care that meets the needs of culturally diverse patients. The model of morality provides a framework that explores how moral motivation and behaviour occur and can provide a vehicle for critically examining the knowledge, skills and attitudes required to provide culturally responsive care.

Ideological tensions amidst rapid and continuous organizational change in healthcare

Purpose

The aim of this study was to explore the nature of frontline nurses' experiences of living with rapid and continuous organizational change.

Design/methodology/approach

A critical hermeneutic approach was utilized. This was a qualitative inquiry theoretically guided by critical management studies.

Findings

Participants recognized that many change initiatives reflected an ideological shift in healthcare that supported a culture of service, whilst sacrificing a culture of care. A culture of service prioritized cost-savings and efficiency, which saw nurses lose the time and resources required to provide quality, safe care.

Practical implications

Nurses felt morally responsible to uphold a culture of care, which proved challenging and at times unobtainable. The inability to provide quality, safe care in light of organizational changes resulted in a multitude of negative emotional repercussions, which fostered moral distress.

Originality/value

The findings from this study bring to light ideological tensions that negatively impact nurses. This study supports the conclusion that the planning, implementation and evaluation of organizational change initiatives must reflect a culture of care in order to alleviate the many negative experiences of organizational change noted in this study.