Moral distress in critical care nurses: a phenomenological study

The Relationship Between Moral Sensitivity, Missed Nursing Care and Moral Distress Among New Nurses: A Cross-Sectional Study

Moral sensitivity, missed nursing care and moral distress among healthcare professionals have received considerable attention in recent years. These factors represent important healthcare challenges for new nurses (graduation to 2 years of work experience). However, studies on the relationships among these variables in the context of new nurses in China remain lacking.

AIMS

To explore the relationships among moral sensitivity, missed nursing care and moral distress in the context of new nurses in China.

RESEARCH DESIGN

A cross-sectional descriptive survey was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 228 new nurses were recruited from three tertiary hospitals in Qingdao, Shandong Province, China. Participants provided their sociodemographic and professional information and completed the Chinese Moral Sensitivity Questionnaire-Revised Version, the Chinese Missed Nursing Care Survey Version and the Chinese Moral Distress Scale-Revised Version. The data were analysed using Spearman's correlation analysis and multiple linear regression analysis.

RESULTS

The means and standard errors of moral sensitivity, missed nursing care and moral distress were 40.71 (0.39), 9.82 (0.78) and 34.87 (2.41), respectively. The variable of missed nursing care exhibited a significant negative relationship with moral sensitivity and a significant positive relationship with moral distress. Regression analysis revealed that the main factors influencing new nurses' moral distress were educational background, nature of job, current unit, frequency of night shifts and the dimensions of moral strength and responsibility. These factors can explain 14.9% of the total variation.

CONCLUSION

The findings revealed that higher rates of missed nursing care were associated with lower moral sensitivity and greater moral distress among new nurses. Therefore, developing interventions to reduce missed nursing care may be a promising strategy for improving moral sensitivity and preventing moral distress among new nurses.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

In hospitals, moral distress can be improved by focusing on modifiable factors such as staffing resources, leading to better promoting new nurses' health and improving the quality of care. This study can highlight practices accounting for moral sensitivity and missed nursing care in nursing research and training programmes.

REPORTING METHOD

Strengthening the reporting of observational studies in epidemiology (STROBE) statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Exploring Ethical Dilemmas and Coping Strategies in Nursing: A Focus Group Study of Nurses and Nursing Students

This study explored the ethical dilemmas and coping behaviors of nurses and students in clinical settings and analyzed their differences. Using separate focus group interviews, 12 nurses and 18 fourth-year nursing students who had completed internships shared their experiences. The results identified two major themes related to ethical dilemmas: Powerlessness and diversity in ethical decision-making. Nurses and students often experienced powerlessness due to the hierarchical structure of healthcare or their lack of experience, making it difficult to navigate complex clinical situations. Coping strategies included demonstrating empathy and patient companionship, enhancing professional literacy, and seeking support from available resources. Participants emphasized the need to strengthen nursing ethics education by focusing on ethical awareness, understanding personal values, and improving communication skills. Strengthening these areas could enhance ethical decision-making, improve professional competence, and support best clinical care practices.

The dual protective role of accountability: Mitigating missed nursing care and nurse moral distress in a nested diary study design

AIMS

To examine a novel moderated-mediation model, investigating whether personal accountability moderates the link between nurse workload and missed nursing care and whether missed nursing care mediates the association between workload and moral distress.

DESIGN

Nested diary study.

METHODS

Data spanning from February 2019 to February 2023 were collected from 137 nurses working in various inpatient wards in two medium-sized hospitals. Nurses reported care given to specific patients on three to five occasions across different shifts, establishing nurse-patient dyads. Validated measures of missed nursing care, personal accountability, moral distress and workload were analyzed using mixed linear models to test the nested moderated-mediation model.

RESULTS

Under high workload conditions, nurses with higher personal accountability reported lower frequencies of missed nursing care compared to those with lower personal accountability. In contrast, under low workload conditions, personal accountability did not significantly influence missed nursing care occurrences. Furthermore, the interaction between workload and personal accountability indirectly affected nurses' moral distress through missed nursing care. Specifically, higher personal accountability combined with lower missed nursing care contributed to reduced levels of moral distress among nurses.

CONCLUSION

The study highlights accountability's dual role-safeguarding against care omissions and influencing nurses' moral distress amid rising workload pressures.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Cultivating a culture of accountability within healthcare settings can serve as a protective factor against the negative effects of workload on patient care quality and nurse psychological distress, highlighting the need for organizational interventions to promote accountability among nursing staff.

IMPACT

By recognizing accountability's pivotal role, organizations can implement targeted interventions fostering accountability among nurses, including training programs focused on enhancing responsibility/ownership in care delivery and creating supportive environments prioritizing accountability to achieve positive patient outcomes.

REPORTING METHOD

The study has adhered to STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Influencing Factors of Nurses' Well-Being in Critical Care During Pandemic Era: A Systematic Review

AIM

To identify factors protecting and hindering the well-being of critical care nurses during the COVID-19 pandemic.

BACKGROUND

The unique work challenges of critical care nurses can undermine their professional and mental well-being; as evidenced by the prevailing literature on burnout, compassion fatigue, and moral distress. The COVID-19 pandemic has seen these professionals on the front lines and has raised many questions about professional well-being. Identifying the factors that protect and hinder the well-being of critical care nurses would help to develop the strategies necessary to reduce worrying phenomena associated with professional malaise.

EVALUATION

A systematic review was conducted using electronic databases including PubMed, CINAHL, Scopus, Cochrane, PsycINFO, and Web on Science.

KEY ISSUES

After full text analysis, 25 papers were included in the current systematic review. Factors influencing the well-being of critical care nurses have been grouped into "Protective" and "Hindering."

CONCLUSIONS

This review shows that critical care nurses' well-being is influenced by factors like personal resilience and supportive work environments, which enhance their experience. Challenges include sociodemographic issues and the COVID-19 pandemic's impact. Addressing these factors is crucial for their well-being and the effectiveness of healthcare systems.

IMPLICATIONS FOR CLINICAL PRACTICE

The well-being of nurses is intricately linked to the quality and security of patient care, ultimately influencing clinical outcomes. This review delves deeply into the multifaceted factors that affect the professional well-being of critical care nurses during the COVID-19 pandemic. Recognizing these elements is critical for directing health policy toward the development of initiatives that bolster healthcare workers' welfare. Prioritizing the professional well-being of nurses is imperative, as it is fundamental in mitigating the increasing inclination towards job turnover, a challenge that is profoundly impacting the healthcare sector.

The relationship between teamwork and moral distress among NICU nurses

BACKGROUND

In the demanding environment of the neonatal intensive care unit (NICU), quality nursing care hinges on effective teamwork and communication among nurses. However, this requirement for close cooperation can expose nurses to significant levels of moral distress. This study aims to explore the connection between the quality of teamwork and the experience of moral distress among NICU nurses.

METHODS

Employing a cross-sectional, multicenter descriptive correlational design, this study surveyed female NICU nurses across the cities of Khorramabad and Semnan. Census sampling was utilized over five months, from July to November 2023, resulting in the participation of 190 nurses. Tools for data collection included demographic questionnaires, the Team-STEPPS Teamwork Perception Questionnaire (T-TPQ), and the Moral Distress Scale-Revised (MDS-R) for nurses.

RESULTS

The findings revealed an average teamwork score of 3.73 ± 0.78, denoting an acceptable level, and an average moral distress score of 91.2 ± 56.7, indicating a low level. In multiple linear regression, marital status showed a direct positive correlation (β = 38.5, SE (β) = 9.3, p < 0.001), while the number of children (β = -14.6, SE (β) = 4.9, p = 0.003) and the teamwork score (β = -1.1, SE (β) = 0.12, p < 0.001) were inversely correlated with moral distress.

CONCLUSION

The study's results suggest that stronger teamwork among nurses correlates with reduced moral distress. Enhancing teamwork within NICUs could lead to policy development focused on the safety and quality of newborn care, also potentially alleviating moral distress experienced by nurses.

Ready to Go Home? Nurses' Perspectives of Prolonged Admission for Patients Undergoing Video-Assisted Thoracic Surgery for Non-Small-Cell Lung Cancer in Denmark

Enhanced recovery after surgery programs with median postoperative hospitalization of 2 days improve outcomes after lung cancer surgery. This article explores nursing care practices for patients with lung cancer who remain hospitalized despite having recovered somatically. Qualitative focus group interviews were conducted with 16 nurses. Ricoeur's phenomenological hermeneutics underpins the methodology applied in this study, and we relied on Benner and Wrubel's theory. The nurses emphasized that the thoughts of patients with a recent lung cancer diagnosis revolve around more than the surgery. Nursing comprises not only practicalities but also attending to patients' stress and their coping with being struck with lung cancer and having undergone surgery. A counterculture emerged to counteract the logic of productivity, indicating that caring as a worthy end in itself may be underestimated in protocol-driven care. Prolonging hospitalization largely depends on clinical judgment. The nurses' aim is not to keep patients in the hospital but to avoid any needless suffering, allowing them to reclaim the primacy of caring.

Factors contributing to moral distress among intensive care nurses: A scoping review

Background: The intensive care unit (ICU) is a busy and complex workplace, and several work-related and personal factors are known to make ICU nurses more vulnerable to moral distress than other healthcare professionals. It is crucial to identify these factors to guide future studies and preventive strategies. This scoping review explores such factors to present current knowledge on the factors that trigger moral distress and to guide future research by reviewing studies to explore and summarize factors that trigger moral distress in ICU nurses. Methods: The PubMed, EBSCO, and CINAHL Plus databases were searched to identify potentially relevant studies published between 2011 to 2022. Inclusion criteria: peer-reviewed studies published in English that provided results regarding factors causes or correlated to moral distress in ICU nurses. After removing 618 duplicates, 316 papers were excluded after title and abstract screening, leaving 71 articles for full-text screening. A further 54 articles were excluded as their outcomes did not include factors that caused moral distress, or were not specific to ICU nurses, so 17 studies were eventually analysed using qualitative content analysis through an inductive approach. The findings of the articles were extracted and coded independently by two authors, and data were grouped and categorized. Results: The content categories of factors contributing to ICU nurses' moral distress were organized into themes and subthemes. Four major themes were identified: Powerlessness, end-of-life care, ineffective teamwork, and personal characteristics of ICU nurses. Conclusions: This review highlights the factors that contribute to moral distress in critical care nurses, which are mainly attributable to the organizational climate and the nature of the ICU clinical environment. Descriptive and intervention studies (experimental or action research) must investigate causality between identified variables to inform management strategies to improve support for ICU nurses' coping relative to moral distress.

Moral distress among critical care nurses before and during the COVID-19 pandemic: A systematic review

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care.

Moral distress, moral resilience, and job embeddedness among pediatric nurses

BACKGROUND

Nurses often face ethical issues in their daily work that can have an impact on their level of job embeddedness. And positive job embeddedness is essential to reduce burnout among nurses and improve professional retention in the medical industry. However, few studies have focused on the relationship between moral distress, moral resilience, and job embeddedness.

OBJECTIVES

To investigate the relationship between moral distress, moral resilience, and job embeddedness, and explore the mediating role of moral resilience between moral distress and job embeddedness among nurses.

DESIGN

A quantitative, cross-sectional study.

METHODS

Nurses from a number of tertiary general hospitals in central China were surveyed and assessed using the Moral Distress Scale, the Nurse Moral Resilience Scale, and the nurse job embeddedness Scale from February to March 2023. The study was conducted in line with the 1964 Declaration of Helsinki.

ETHICAL CONSIDERATION

All study procedures were approved by the Ethics Committee of Hunan Normal University (No. 2023-313).

FINDINGS

Moral distress was positively correlated with moral resilience (β = 0.525, p < 0.01) and negatively correlated job embeddedness (β = -0.470, p < 0.01). Moral resilience partially mediated the relationship between moral distress with job embeddedness (β = -0.087, p < 0.01).

DISCUSSION

The findings reveal a relationship between moral distress, job embeddedness, and moral resilience among nurses.

CONCLUSION

Moral distress and moral resilience are important correlates of job embeddedness in nurses. Interventions to reduce moral distress and increase moral resilience may have potential benefits for improving nurses' job embeddedness. It is recommended that clinical nursing administrators create a favorable ethical atmosphere, educate nurses about ethics, and increase nurses' moral resilience.

Neonatal nurses' educational needs in a family-centered partnership program: Five ways of knowing

BACKGROUND

Partnerships between parents and nurses are essential to provide comprehensive family-centered care (FCC) in the neonatal intensive care unit (NICU).

OBJECTIVES

We aimed to identify the educational needs of neonatal nurses to develop a family-centered partnership program with parents based on five ways of knowing.

DESIGN

We conducted focus group interviews with 18 NICU nurses working at a tertiary hospital. Data were analyzed using inductive content analysis.

METHOD

Data were collected from February to March 2023 through semi-structured interviews and then carefully transcribed and analyzed using a qualitative content analysis approach.

RESULTS

We used Carper and Chinn and Kramer's five ways of knowing as a framework for data analysis. Twelve categories emerged: staying updated with evidence-based practice, recognizing FCC, practicing neonatal nursing skills and participating in continued education and professional development (empirical knowledge); engaging in self-reflection and expressing therapeutic empathy (personal knowledge); fostering effective communication and leading cooperative readership, building integrity (esthetic knowledge); maintaining ethical responsibility (ethical knowledge); and developing collaborative teamwork, growing cultural competence (emancipatory knowledge).

CONCLUSIONS

This study could be used as a foundation for enhancing NICU nurses' partnerships with parents based on FCC and nurses' educational needs and preferences.

Nursing Ethical Decision Making on Adult Physical Restraint: A Scoping Review

OBJECTIVE

to map the existing knowledge on nursing ethical decision making in the physical restraint of hospitalised adults. (1) Background: physical restraint is a technique that conditions the free movement of the body, with risks and benefits. The prevalence of physical restraint in healthcare suffers a wide variation, considering the environment or pathology, and it raises ethical issues that hinders decision making. This article intends to analyse and discuss this problem, starting from a literature review that will provoke a grounded discussion on the ethical and legal aspects. Inclusion criteria are: studies on physical restraint (C) and ethical nursing decision making (C) in hospitalized adults (P); (2) methods: a three-step search strategy was used according to the JBI. The databases consulted were CINAHL Plus with Full Text (EBSCOhost), MEDLINE Full Text (EBSCOhost), Nursing and Allied Health Collection: Comprehensive and Cochrane Database of Systematic Reviews (by Cochrane Library, RCAAP and Google Scholar. All articles were analysed by two independent reviewers; (3) results: according to the inclusion criteria, 18 articles were included. The categories that influence ethical decision in nursing are: consequence of the decision, the context, the nature of the decision in terms of its complexity, the principles of the ethical decision in nursing, ethical issues and universal values; (4) conclusions: the findings of this review provide evidence that there is extensive knowledge regarding nursing ethical decision making in adult physical restriction, also, it is considered an ethical issue with many associated assumptions. In this article we aim to confront all these issues from a legal perspective.

Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity

AIM

To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness.

DESIGN & METHODS

A discursive paper, drawing on clinical experience and research of the authors and current literature.

RESULTS

Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care.

PATIENT AND PUBLIC INVOLVEMENT

This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BACKGROUND

Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied.

OBJECTIVE

The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia.

METHODS

An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated.

RESULTS

A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement.

CONCLUSION

The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

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.

Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses

BACKGROUND

Healthcare professionals often experience moral distress while providing end-of-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea.

METHODS

This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory.

RESULTS

Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation.

CONCLUSION

Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Nurse views of obstacles encountered by nurses in Saudi Arabia during the provision of psychiatric care

BACKGROUND

Nursing staff within the mental health sector are major actors in delivering healthcare. They face considerable obstacles that may hinder the provision of high-quality care to patients with mental health challenges.

AIM

The current study offers a description of mental health nurses' viewpoints, insights into obstacles encountered during their experiences, and recommendations for enhancing psychiatric inpatient nursing care and achieving progress toward the goals set out by Saudi Vision 2030.

METHODS

The study employed a phenomenological qualitative design. Semistructured interviews were conducted with 10 currently practicing mental health nurses during two focus group sessions. The inductive data produced underwent member and peer checking. Emergent themes and subthemes were extracted.

RESULTS

Two main themes and related subthemes were identified. The first theme-obstacles faced by mental health nurses-was composed of the following subthemes: policy at institutions; clear job roles; low professional self-confidence and inadequate support; stressed, insecure, and unsafe; and stigmatization. The second theme-recommendations to improve the quality of mental health nursing-was composed of two subthemes: to enhance mental health awareness and improve professional skills and education.

CONCLUSION

The data suggest that maintaining high-quality nursing standards within an inpatient psychiatric facility requires a consistent and accountable organizational structure, which can lead to fostering the development and improvement of relevant nursing skills through continuing education, improved awareness of mental health disorders and care within the community, and initiatives to combat the stigma of mental disorders among patients, families, and communities.

Moral distress among intensive care unit professions in the UK: a mixed-methods study

OBJECTIVE

To assess the experience of moral distress among intensive care unit (ICU) professionals in the UK.

DESIGN

Mixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews.

SETTING

Four ICUs of varying sizes and specialty facilities.

PARTICIPANTS

Healthcare professionals working in ICU.

RESULTS

227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient's wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention.

CONCLUSIONS

Moral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Moral distress: Does this impact on intent to stay among adult critical care nurses?

BACKGROUND

Moral distress is recognized as an international problem that contributes to decreased work productivity, job dissatisfaction and intent to leave for adult Critical Care nurses.

AIM

To explore Critical Care nurses moral distress levels using the Moral Distress Scale Revised (MDS-R) and its relationship with intention to stay. The study reported in this paper was part of a larger study that also investigated Critical Care nurses' work environment in Canada and the Midlands region of the UK.

STUDY DESIGN

During January to August 2017 a cross-sectional survey was distributed to adult Critical Care nurses in the Midlands region of the UK.

METHODS

Surveys were distributed to adult Critical Care Registered Nurses in the Midlands region of the UK examining moral distress levels and intention to stay in Critical Care, the organization (NHS Trust) and in the nursing profession.

RESULTS

Two hundred sixty-six number of a potential sample of 1066 Critical Care nurses completed the survey (25% response rate). Age and moral distress were significantly positively correlated with intention to stay on their current unit (r = 0.16, P = .05), indicating older nurses were more likely to stay in the critical care unit. Moral distress was negatively correlated with intent to stay scores, showing critical care nurses with higher levels of moral distress were less likely to stay on their unit (r = -0.20, P = .02). Moral distress was also significantly negatively correlated with intention to stay with their current employer (r = -0.28, P < .001). Nurses that stated they had high rates of moral distress were more likely to consider leaving their current employer.

CONCLUSION

Moral distress appears to be an issue among adult Critical Care nurses requiring further exploration and development of effective strategies to reduce this phenomenon and stabilize the workforce by reducing turnover.

RELEVANCE TO CLINICAL PRACTICE

By identifying the top causes of moral distress, tools and strategies can be developed to allow the Critical Care nurse to work within an ethically safe clinical environment and reduce the turnover of experienced adult Critical Care nurses.

Identifying Sources of Moral Distress Amongst Critical Care Staff During the Covid-19 Pandemic Using a Naturalistic Inquiry

Introduction

Moral distress can have a significant impact on the mental health and well-being of practitioners. Causes of moral distress in critical care have been identified as futile treatment, conflict between family members and staff, lack of resources, and dysfunctional teams.

Objectives

This study explores the sources of moral distress during the COVID-19 pandemic and the meaning that staff attached to these events. The study aims to examine whether the sources of moral distress are similar, or different, to those that commonly occur in critical care departments.

Methods

Naturalistic inquiry using semi-structured individual interviews with 17 participants drawn from nursing ( n = 12), medicine ( n = 3), and the allied health professions ( n = 2). The interviews were recorded and transcribed verbatim. The transcripts were analyzed using reflexive thematic analysis.

Results

The results suggested that while there were some similar sources of moral distress including caring for dying patients and not being able to provide the usual standard of care, the nature of the disease trajectory and frequency of death had a significant impact. In addition, the researchers found that providing care which was counter-intuitive, concerns about the risks to the staff and their families and the additional burdens associated with leading teams in times of uncertainty were identified as sources of moral distress.

Conclusion

This study explored the potential sources of moral distress during the pandemic and the meaning that practitioners attached to their experiences. There were some similarities with the sources of moral distress in critical care which occur outside of a pandemic. However, the frequency and intensity of the experiences are likely to be different during a pandemic, with staff describing high volumes of deaths without family members present. In addition, new sources of moral distress related to uncertainty, counter-intuitive care and concerns about personal and family risk of infection were identified.

Moral Distress of Intensive Care Nurses: A Phenomenological Qualitative Study Two Years after the First Wave of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has imposed great pressure on healthcare facilities, exposing healthcare professionals to various challenges that may result in the onset of moral distress, a condition of psychological distress caused by the inability to act as it would be most morally appropriate. The purpose of this research was to investigate the experience lived by nurses who worked in an intensive care unit during the COVID-19 pandemic.

METHODS

This is a phenomenological study using interpretative phenomenological analysis. Sixteen nurses who worked in the COVID-19 Intensive Care Unit of Northern Italian Hospitals from January to April 2022 were selected through purposive sampling. Data on experiences, thoughts, and symptoms were collected through semi-structured interviews with in-person and remote modalities.

RESULTS

Five themes and fourteen subthemes emerged from the study. The themes are: (1) pride, isolation, and fear; (2) teamwork and organisation; (3) moral/ethical aspect; (4) true heroes; and (5) dignity.

CONCLUSIONS

This study highlights the impact of the COVID-19 pandemic on intensive care unit nurses. It has emerged that the risk of moral distress is high among healthcare workers in the front line of the fight against the virus. This condition should be avoided and managed through early psychological interventions, sharing of experiences, and a good organization that supports decision-making and professional well-being.

How do ethically competent nurses behave in clinical nursing practice? A qualitative study

AIM

This study explored how ethically competent nurses behave in clinical nursing practice.

BACKGROUND

Nurses' ethical competency is crucial in nursing practice as it promotes patients' safety and quality of care.

METHODS

Using a purposive sampling technique, 20 clinical nurses in South Korea were interviewed via an online video platform. The data were analysed using a thematic analysis based on phenomenological approach.

RESULTS

The main theme found among the participating nurses' ethical competency was caring beyond egocentrism, with two subthemes: (1) patient-centred care based on compassion and (2) responsible behaviour based on nursing professionalism. Factors that enabled this included (1) reasonable work conditions, (2) interpersonal relationships, and (3) nurses' rich personal experiences.

CONCLUSIONS

Nurses' ethical competency depends on how far they can move away from their own egocentrism and act for their clients' benefit, wherein an appropriate workload and warm human relationships with one's colleagues are essential. Nurses should thus receive education on ethics and professionalism and participate in volunteer and leisure activities that cultivate their degree of empathy.

IMPLICATION FOR NURSING MANAGEMENT

Nursing leaders and managers should understand nurses' ethical competency and its enabling factors to devise effective strategies to promote it.

Arab nursing students' perception of the emotional experience of patient care: A phenomenological study

BACKGROUND

A shared emotional response helps with understanding what other people are feeling and/or thinking; and it is a vital skill in clinical settings. Collectivist communities place more emphasis on the emotional components of their feelings in comparison to the cognitive aspects of their emotions.

PURPOSE

This study aimed to explore the emotions experienced by students at their first clinical placement.

METHODS

A hermeneutic phenomenological approach was used among nine baccalaureate students.

RESULTS

Three major themes emerged from the data: overwhelming emotions; unbalanced perception of professional identity; and adjustment and adaptation.

CONCLUSIONS AND DISCUSSION

It is evident that nursing students from collectivist communities encounter challenges in dealing with their emotions and managing their patients' emotions; however, they were capable of empathizing with their patients using the two components of their empathy; affective (emotion) and cognitive (cognition), with prominence given to the affective part. As countries become increasingly multi-cultural, which in turn influences the characteristics of people entering pre-registration nursing programs, nursing leaders are invited to address both dimensions of empathy as part of the nursing curriculum. Attention should also be given in clinical settings to appropriate channeling of clinical empathy to cultivate a professional identity.

Culturally-sensitive moral distress experiences of intensive care nurses: A scoping review

BACKGROUND

Moral distress is a phenomenon that all nurses experience at different levels and contexts. The level of moral distress can be affected by individual values and the local culture. The sources of the values shape the level of moral distress experienced and the nurses' decisions.

AIM

The present scoping review was conducted to examine the situations that cause moral distress in ICU nurses in different countries.

RESULTS

A scoping review methodology was adopted for the study, in line with the approach of Arksey, and O'Malley Literature was searched within PubMed/Medline, Scopus, Web of Science, and PsycINFO indexed keywords such as "moral distress", "Critical Care Nurse", and "Moral Distress Scale-Revised". Of the 617 identified citations, 12 articles matched the inclusion criteria.

CONCLUSION

The moral distress experienced in countries and regions with similar cultures and geographies was parallel. The situations that cause the most moral distress are futile-care to prolong death, unnecessary tests and treatments, and working with incompetent healthcare personnel.

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.

Towards democratic institutions: Tronto's care ethics inspiring nursing actions in intensive care

Care as a concept has long been central to the nursing discipline, and care ethics have consequently found their place in nursing ethics discussions. This paper briefly revisits how care and care ethics have been theorized and applied in the discipline of nursing, with an emphasis on Tronto's political view of care. Adding to the works of other nurse scholars, we consider that Tronto's care ethics is useful to understand caring practices in a sociopolitical context. We also contend that this vision can be used specifically to politicize nurses, by encouraging them to think critically about the context in which they work and how they can participate to change the status quo, notably by prompting the democratization of care in institutional settings. We illustrate this by demonstrating how moral distress that can occur with aggressive or futile treatments in the intensive care unit can be reduced if nurses are systematically included in the decision-making process. By showing some ways in which nursing political actions can begin to change the status quo as it pertains to futile treatments at the end of life, we can help empower nurses to strive to be included in political spaces and voice their concerns to have their professional needs met.

A critical incident study of ICU nurses during the COVID-19 pandemic

BACKGROUND

Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses' sources of distress is important when planning interventions to support them.

PURPOSE

To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic.

DESIGN

Qualitative descriptive component within a larger mixed-methods study.

PARTICIPANTS AND RESEARCH CONTEXT

Participants were invited to write down their experiences of a critical incident, which distressed them when providing nursing care. Thematic analysis was used to analyze the data.

ETHICAL CONSIDERATIONS

The study was approved by the ethics committee at the researchers' university in eastern Canada.

RESULTS

A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families' grief, (3) our safety, and (4) futility of care. Many nurses' stories also focused on the organizational preparedness of their institutions and concerns over their own safety.

DISCUSSION

Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed.

CONCLUSION

Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses' well-being.

Effective interventions for reducing moral distress in critical care nurses

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, as well as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses.

One size does not fit all - overcoming barriers to participant recruitment in qualitative research

BACKGROUND

It can be challenging to recruit participants for qualitative research. Recruitment can be affected by factors such as systemic barriers, as well as potential participants being reluctant to enrol in research they view as time-consuming and burdensome - particularly research exploring sensitive topics.

AIM

To analyse and describe the implementation of multiple recruitment strategies used to overcome the recruitment barriers in a qualitative study exploring the use of physical restraints during mechanical ventilation in intensive care.

DISCUSSION

Recruitment strategies that are helpful for one study may not be successful in another. Qualitative researchers may face many recruitment challenges specific to the contexts of their studies. Overcoming these challenges can be costly, time-consuming and often frustrating, so it is important that researchers develop qualities and skills that enable them to navigate these barriers.

CONCLUSION

Nurse researchers must consider the contexts of their target populations and tailor their recruitment strategies to the populations' needs. They must also be flexible, innovative and persistent in their approach, despite the challenges they face.

IMPLICATIONS FOR PRACTICE

This paper provides insights into the recruitment barriers faced during a qualitative study and possible solutions. These insights can guide nurse researchers facing similar challenges in qualitative research.

Work interruptions and missed nursing care: A necessary evil or an opportunity? The role of nurses' sense of controllability

AIM

To explore nurses' experiences with work interruptions (WIs) through the lens of missed nursing care (MNC).

DESIGN

A qualitative descriptive design.

METHODS

Eleven small focus groups involving 34 nurses (three nurses per group on average) from acute-care hospital wards were conducted. Nurses shared their experiences with WIs (sources, reactions and decisions) from the MNC perspective. Data analysis was conducted via content analysis.

RESULTS

A preponderant theme emerged-the dynamic of controllability. Nurses who perceived a sense of controllability felt that they could decide whether to accept or reject the WI, regardless of WI type, and emotions of anger emerged. Conversely, nurses who did not perceive sense of controllability attended the secondary task: MNC occurred, and distress emotions emerged. Results emphasized that nurses are active agents prioritizing whether to omit or complete care in the face of WIs. Controllability, accompanied by active negative emotions, perpetuate a prioritization process that makes it less probable that MNC occurs.

Nurses' Views on the Use of Physical Restraints in Intensive Care: A Qualitative Study

Despite the worldwide promotion of a “restraint-free” model of care due to the questionable ethical and legal issues and the many adverse physical and psychosocial effects of physical restraints, their use remains relatively high, especially in the intensive care setting. Therefore, the aim of the present study was to explore the experiences of nurses using physical restraints in the intensive care setting. Semi-structured interviews with 20 nurses working in intensive care units for at least three years, were conducted, recorded, and transcribed verbatim. Then, the transcripts were analyzed according to the qualitative descriptive approach by Sandelowsky and Barroso (2002). Six main themes emerged: (1) definition of restraint, (2) who decides to restrain? (3) reasons behind the restraint use, (4) physical restraint used as the last option (5) family involvement, (6) nurses’ feelings about restraint. Physical restraint evokes different thoughts and feelings. Nurses, which are the professionals most present at the patient’s bedside, have been shown to be the main decision-makers regarding the application of physical restraints. Nurses need to balance the ethical principle of beneficence through this practice, ensuring the safety of the patient, and the principle of autonomy of the person.

Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study

AIM AND OBJECTIVES

To describe nurses' experiences of using restraint in neurosurgical care.

BACKGROUND

Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce.

DESIGN

A qualitative, descriptive design guided by a naturalistic inquiry was used.

METHODS

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist.

RESULTS

The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines.

CONCLUSION

Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Moral injury in healthcare professionals: A scoping review and discussion

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

Beyond technology, drips, and machines: Moral distress in PICU nurses caring for end-of-life patients

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long-term consequences to the individual. Critical care areas are fraught with ethical issues, and end-of-life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality.

Moral distress among nurses: A mixed-methods study

BACKGROUND

Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand.

OBJECTIVE

This study aims to describe the experience of moral distress and related factors among Thai nurses.

DESIGN

A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated.

PARTICIPANTS

Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand.

ETHICAL CONSIDERATIONS

This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151.

RESULTS

A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress.

DISCUSSION

Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient's and family's religious perspective that ties into the concept of moral distress needs to be explored.

CONCLUSIONS

Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context.

Understanding nurses' perspectives of physical restraints during mechanical ventilation in intensive care: A qualitative study

AIMS AND OBJECTIVES

This study explored the experiences of nurses using physical restraints on mechanically ventilated patients in intensive care.

BACKGROUND

Physical restraints are frequently used to prevent treatment interference and maintain patient safety in intensive care units worldwide. However, physical restraints are found to be ineffective in preventing treatment interference and cause negative outcomes for patients. The practices surrounding physical restraints are inconsistent due to a lack of education, training and protocols.

DESIGN

This research was conducted as a qualitative study with a naturalistic inquiry framework adhering to the Consolidated Criteria for Reporting Qualitative Research guidelines.

METHODS

Twelve in-depth, semi-structured conversations were conducted with registered nurses who have experience working in intensive care and have cared for patients who were physically restrained and mechanically ventilated. These conversations were audio-recorded and transcribed. Thematic analysis was used to analyse the data.

RESULTS

Three major themes emerged from the data. The themes were as follows: the ICU culture and its impacts on physical restraint practices; the consequences of physical restraints through a nursing lens; and understanding the ways of learning.

CONCLUSION

The insights into the ICU culture, the nurses' understanding of the consequences of physical restraints and the ways in which nurses learn physical restraint practices have provided a greater depth of knowledge and understanding of the realities of current practice in ICU. This new information demonstrates nurses' understanding of the potential harm caused by physical restraints and the way in which current practices are guided more-so by workplace norms and expectations rather than on critical thinking and decision-making.

RELEVANCE TO CLINICAL PRACTICE

These insights provide valuable information to intensive care clinicians, educators and policymakers to guide future practice and improve patient outcomes by highlighting the importance of education on physical restraint practices and informing the development of policies and guidelines.

Coronavirus Disease 2019 Immediately Increases Burnout Symptoms in ICU Professionals: A Longitudinal Cohort Study

OBJECTIVES

ICU professionals are at risk of developing burnout due to coronavirus disease 2019. This study assesses the prevalence and incidence of burnout symptoms and moral distress in ICU professionals before and during the coronavirus disease 2019 crisis.

DESIGN

This is a longitudinal open cohort study.

SETTING

Five ICUs based in a single university medical center plus another adult ICU based on a separate teaching hospital in the Netherlands.

SUBJECTS

All ICU professionals were sent a baseline survey in October-December 2019 (252 respondents, response rate: 53%), and a follow-up survey was sent in May-June 2020 (233 respondents, response rate: 50%).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Burnout symptoms and moral distress measured with the Maslach Burnout Inventory and the Moral Distress Scale, respectively. The prevalence of burnout symptoms was 23.0% before coronavirus disease 2019 and 36.1% at postpeak time, with higher rates in nurses (38.0%) than in physicians (28.6%). Reversely, the incidence rate of new burnout cases among physicians was higher (26.7%) than nurses (21.9%). Higher prevalence of burnout symptoms was observed in the postpeak coronavirus disease 2019 period (odds ratio, 1.83; 95% CI, 1.32-2.53), for nurses (odds ratio, 1.77; 95% CI, 1.03-3.04), for professionals working overtime (odds ratio 2.11; 95% CI, 1.48-3.02), and for professionals directly engaged with care for coronavirus disease 2019 patients (odds ratio, 1.87; 95% CI, 1.35-2.60). Physicians were more likely than nurses to develop burnout symptoms due to coronavirus disease 2019 (odds ratio, 3.56; 95% CI, 1.06-12.21).

CONCLUSIONS

This study shows that overburdening of ICU professionals during an extended period of time leads to symptoms of burnout. Working long hours and under conditions of scarcity of staff, time, and resources comes at the price of ICU professionals' mental health.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units

AIM

To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting.

BACKGROUND

During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex.

SOURCES OF EVIDENCE

Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication.

DISCUSSION

The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research.

CONCLUSIONS

Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

Moral neutralization: Nurses' evolution in unethical climate workplaces

Introduction

Good quality of care is dependent on nurses’ strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice.

Materials and methods

This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews.

Results

The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: (1) feeling discouraged; (2) normalization; (3) giving up; (4) becoming a justifier; and (5) moral indifference.

Conclusions

Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process.

A Case-Centered Approach to Nursing Ethics Education: A Qualitative Study

Nurses deal with ethical decisions as they protect patients’ rights, but a consensus on effective approaches to nursing ethics education is lacking. The “four topics” method can facilitate decision-making when nurses experience ethical dilemmas in practice. This study aimed to describe nursing students’ perspectives on and experiences of a case-centered approach to nursing ethics education using the four topics method. This qualitative study consisted of two phases. First, we delivered case-centered nursing ethics education sessions to nursing students using the four topics method. Then, we conducted two focus group discussions that explored students’ perspectives on and experiences of nursing ethics education. Data were analyzed using conventional content analysis. Four themes were identified: the importance of ethics education as perceived by nursing students, problems in current nursing ethics education, the experience of case-centered nursing ethics education using the four topics approach, and suggestions for improving nursing ethics education. The case-centered approach using the four topics method is effective in enhancing nursing students’ nursing ethics ability. It is crucial to understand that nursing students would like to set up their own ethical standards and philosophy. Continuous efforts to encourage students’ participation and to provide ethical reflection opportunities during clinical practice are needed to better connect theory with clinical practice.

Safe and competent nursing care: An argument for a minimum standard?

There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient's actual situation is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients' needs and legal rights to healthcare and on nurses' codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients' needs in different settings and may thus be different in different contexts and countries.

Moral distress in emergency and critical care nurses: A metaethnography

BACKGROUND

Moral distress has detrimental effects on nurses which impacts the entire healthcare cycle. Described as a crescendo effect, resolved situations of moral distress leave residue on the nurse with three potential outcomes: moral numbing, conscious objection to the situation, and burnout.

OBJECTIVE

This metaethnography strives to achieve a fuller understanding of moral distress by interpreting the body of qualitative work of moral distress in emergency and critical care nurses.

METHOD

This study used the Noblit and Hare's approach of interpretative synthesis. Ten studies met the criteria and were used in this synthesis.

ETHICAL CONSIDERATIONS

Ethical issues were minimal since no human subjects were involved. Ethical requirements were respected in all study phases.

RESULTS

The synthesis of qualitative research on moral distress resulted in one central theme, "the battle within," and five subthemes.

CONCLUSIONS

The unique nature of this nursing specialty resulted in a lasting inner conflict for nurses that is consistent with the previously described crescendo effect. The effects are complex and long lasting and may potentially affect the nurses' future patient care.

Giving nurses a voice during ethical conflict in the ICU

BACKGROUND

Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit. There is a gap in our understanding of nurses' perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit.

RESEARCH QUESTION/OBJECTIVES/METHODS

The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice.

PARTICIPANTS AND RESEARCH CONTEXT

Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States.

ETHICAL CONSIDERATIONS

This study was approved by the Institutional Review Board at the organization where the study took place.

FINDINGS

Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict.

DISCUSSION

Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict.

CONCLUSION

These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.

Ethical Conflicts Experienced by Nurses in Geriatric Hospitals in South Korea: "If You Can't Stand the Heat, Get Out of the Kitchen"

Ethical conflicts among nurses can undermine nurses’ psychological comfort and compromise the quality of patient care. In the last decade, several empirical studies on the phenomena related to ethical conflicts, such as ethical dilemmas, issues, problems, difficulties, or challenges, have been reported; however, they have not always deeply explored the meaning of ethical conflicts experienced by nurses in geriatric care. This study aims to understand the lived experiences of ethical conflict of nurses in geriatric hospitals in South Korea. A phenomenological study was conducted. In-depth, face-to-face interviews were performed with nine registered nurses who cared for elderly patients in geriatric hospitals in South Korea between August 2015 and January 2016. Three main themes emerged from the analysis: (1) confusing values for good nursing, (2) distress resulting from not taking required action despite knowing about a problem, and (3) avoiding ethical conflicts as a last resort. It was found that for geriatric nurses to cope with ethical conflicts successfully, clear ethical guidance, continuing ethics education to improve ethical knowledge and moral behaviors, and a supportive system or program to resolve ethical conflicts involving nurses should be established.

Exploring the meaning of critical incident stress experienced by intensive care unit nurses

The complexity of registered nurses' work in the intensive care unit places them at risk of experiencing critical incident stress. Gadamer's philosophical hermeneutics (1960/2013) was used to expand the meanings of work-related critical incident stress for registered nurses working with adults in the intensive care unit. Nine intensive care unit registered nurses participated in unstructured interviews. The interpretations emphasized that morally distressing experiences may lead to critical incident stress. Critical incident stress was influenced by the perception of judgment from co-workers and the organizational culture. Nurses in this study attempted to cope with critical incident stress by functioning in 'autopilot', temporarily altering their ability to critically think and to conceal emotions. Participants emphasized the importance of timely crisis interventions tailored to support their needs. This study highlighted that critical incident stress was transformative in how intensive care unit nurses practiced, potentially altering their professional self-identity. Work-related critical incident stress has implications for nurses, the discipline, and the health care system.

Visibility of nursing in policy documents related to health care priorities

AIM

To explore the visibility of nursing in policy documents concerning health care priorities in the Nordic countries.

BACKGROUND

Nurses at all levels in health care organisations set priorities on a daily basis. Such prioritization entails allocation of scarce public resources with implications for patients, nurses and society. Although prioritization in health care has been on the political agenda for many years, prioritization in nursing seems to be obscure in policy documents.

METHODOLOGY

Each author searched for relevant documents from their own country. Text analyses were conducted of the included documents concerning nursing visibility.

RESULTS

All the Nordic countries have published documents articulating values and criteria relating to health care priorities. Nursing is seldom explicitly mentioned but rather is included and implicit in discussions of health care prioritization in general.

CONCLUSION

There is a need to make priorities in nursing visible to prevent missed nursing care and ensure fair allocation of limited resources.

IMPLICATIONS FOR NURSING MANAGEMENT

To highlight nursing priorities, we suggest that the fundamental need for nursing care and what this implies for patient care in different organisational settings be clarified and that policymakers explicitly include this information in national policy documents.

Greek nurses' perceptions on empathy and empathic care in the Intensive Care Unit

BACKGROUND

Empathy is a fundamental component of nursing practice impacting positively on the therapeutic process. Understanding the concepts of empathy and empathic care in the context of Intensive Care Units is essential for providing better care in high challenging environments. However, research on empathy in the ICU is scarce and mostly quantitative.

OBJECTIVES

To explore how ICU nurses perceive the concepts of empathy and empathic care.

DESIGN AND SETTING

A descriptive qualitative research design was applied using an inductive content analysis approach. Semi-structured interviews were conducted with nineteen ICU nurses in two hospitals in Greece.

FINDINGS

Data analysis revealed three main themes namely: "To become one of them", "Empathic Care" and "Integration of empathic care in practice". Findings corroborated the affective, cognitive and behavioral components of empathy. Nurses underlined that understaffing, increased workload and professional burnout impeded empathic care.

CONCLUSION

Empathy and empathic care in the ICU were perceived as closely related to patients' outcomes and quality care. Empathic care was arduous due to organisational issues. Despite that, ICU nurses appeared to promote empathic care in practice and sought ways to enhance it.