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Wilson MA, Shay A, Harris JI, Faller N, Usset TJ, Simmons A. Moral Distress and Moral Injury in Military Healthcare Clinicians: A Scoping Review. AJPM FOCUS 2024; 3:100173. [PMID: 38304024 PMCID: PMC10832382 DOI: 10.1016/j.focus.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Introduction Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member. Methods A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies. Results A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis. Discussion This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.
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Affiliation(s)
- Melissa A. Wilson
- U.S. Air Force Research Laboratory, Dayton, Ohio
- College of Health, Education and Human Services Department of Nursing, Wright State University, Dayton, Ohio
| | - Amy Shay
- School of Nursing, Indiana University, Indianapolis, Indiana
| | | | | | - Timothy J. Usset
- Division of Health Policy & Management, University of Minnesota, Minneapolis, Minnesota
| | - Angela Simmons
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Thomas TA, Kumar S, Davis FD, Boedeker P, Thammasitboon S. Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals. AJOB Empir Bioeth 2024; 15:120-132. [PMID: 38165288 DOI: 10.1080/23294515.2023.2297922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress. DESIGN Cross-sectional survey. SETTING Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States. PARTICIPANTS Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study. MAIN OUTCOME MEASURES Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM). RESULTS Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82). CONCLUSIONS We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.
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Affiliation(s)
- Tessy A Thomas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Health System, Danville, PA, USA
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Shelley Kumar
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - F Daniel Davis
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Peter Boedeker
- Department of Education, Innovation and Technology, Baylor College of Medicine, Houston, TX, USA
| | - Satid Thammasitboon
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Zhang W, Zhu Q, Yu R, He T, Huang J. Regulatory focus as a mediator in the relationship between nurses' organizational silence and professional identity. J Adv Nurs 2024. [PMID: 38380591 DOI: 10.1111/jan.16113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
AIMS This work aims to analyse the current state of the professional identity of Chinese nurses; examine the relationship amongst regulatory focus, organizational silence and professional identity and determine how regulatory focus affects the relationship between professional identity and organizational silence. DESIGN This study conducted a cross-sectional survey. METHODS From June to August 2023, 420 nurses from six hospitals in Hunan Province, China, were selected through convenience sampling and surveyed by using a general information questionnaire, the regulatory focus scale, the organizational silence scale and the professional identity scale. The relationship amongst the regulatory focus, organizational silence and professional identity of nurses was examined by utilizing SPSS 25.0 and the mediating role of regulatory focus between organizational silence and nurses' professional identity was examined by applying AMOS 24.0. RESULTS Nurses had a moderate level of professional identity. Professional identity was positively correlated with regulatory focus and negatively correlated with organizational silence. Regulatory focus was negatively correlated with organizational silence. Mediation effect studies revealed that organizational silence and professional identity were partially mediated by regulatory focus. CONCLUSION In accordance with research showing that nurses' organizational silence can indirectly affect professional identity via regulatory focus, clinical nursing managers should concentrate on the interaction amongst these three variables to strengthen professional identity. IMPACT The results of this study serve as a reminder to nurses to select a preventive or promotive focus based on their career objectives and to effectively express their views to enhance their professional identity. This also reminds nursing managers assess nurse-led regulatory focus, identify their underlying qualities and understand their professional aspirations and career orientation, create a good atmosphere for advice and encourage nurses to express their views, so as to improve nurses 'professional identity. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Wenxia Zhang
- School of Nursing, Hunan University of Chinese Medicine, Changsha, China
| | - Quanli Zhu
- Hunan Academy of Traditional Chinese Medicine Affiliated Hospital, Changsha, China
| | - Renhe Yu
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Taotao He
- School of Nursing, Hunan University of Chinese Medicine, Changsha, China
| | - Jing Huang
- Hunan Academy of Traditional Chinese Medicine, Changsha, China
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Berdida DJE, Grande RAN. Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis. JOURNAL OF RELIGION AND HEALTH 2023; 62:3957-3978. [PMID: 37442900 DOI: 10.1007/s10943-023-01873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
Investigations about moral resilience and moral courage as mediators between moral distress and moral injury remain underreported among nurses during the COVID-19 pandemic. Nurses (n = 412) from the Philippines were conveniently recruited via social media platforms and completed four self-report scales. The mediation model depicts that moral distress negatively impacts moral resilience and moral courage while positively affecting moral injury. Moral resilience and moral courage negatively impact moral injury, whereas moral resilience directly impacts moral courage. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. Findings indicate that healthcare organizations and nurse managers should nurture morally resilient and courageous therapeutic practices among frontline healthcare professionals to mitigate the negative effects of moral distress and moral injury.
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Affiliation(s)
- Daniel Joseph E Berdida
- College of Nursing, University of Santo Tomas, St. Martin de Porres Bldg., España Boulevard, 1015, Manila, Philippines.
| | - Rizal Angelo N Grande
- Mental Health Nursing Department, College of Nursing, University of Ha'il, Ha'il, 55473, Kingdom of Saudi Arabia
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Berdida DJE. The mediating roles of moral courage and moral resilience between nurses' moral distress and moral injury: An online cross-sectional study. Nurse Educ Pract 2023; 71:103730. [PMID: 37499534 DOI: 10.1016/j.nepr.2023.103730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
AIMS To investigate the mediating role of moral resilience and moral courage in the association between moral distress and moral injury. BACKGROUND There is a preponderance of nursing literature about moral distress, moral resilience, moral courage and moral injury. However, examining moral resilience and moral courage as mediators remain underreported during the COVID-19 pandemic and in the context of a developing nation. DESIGN Correlational, cross-sectional design compliant with the STROBE guidelines. METHODS A convenience sample of nurses (n = 412) from the Philippines were recruited using social media platforms (e.g., Facebook, Messenger, Twitter). Four self-report and validated scales (8-item Moral-Distress Appraisal Scale, 21-item Nurses' Moral Courage Scale, 17-item Rushton Moral Resilience Scale and 10-item Moral Injury Symptom Scale: Healthcare Professionals Version) were used to collect data from January to July 2022. Pearson's r, bivariate analysis and multistage regression analyses were used for data analysis. RESULTS This study afforded a model that depicted the interrelationships of moral distress, moral resilience, moral courage and moral injury. Moral distress has a negative impact on moral resilience and moral courage while positively affecting moral injury. Moral resilience positively influences moral courage while having a negative impact on moral injury. Moral courage has an indirect impact on moral injury. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. CONCLUSIONS Healthcare organizations, policymakers and nurse managers should include policies and programs that include improving approaches to modifying workplace conditions and evaluating nurses' moral resilience and courage. Nurse managers need to advocate ethics education and professionalism. Nurses must practice self-care strategies to strengthen morally resilient and courageous therapeutic practices.
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Affiliation(s)
- Daniel Joseph E Berdida
- College of Nursing, University of Santo Tomas, Manila 1015, Philippines; College of Graduate Studies and Teacher Education Research (CGSTER), Philippine Normal University, Taft Ave., Manila 1000, Philippines.
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Baskwill A, Hay P, Calleri F, Fiddes L, Barnett R, Fogarty S. The paradox of the impact of the COVID-19 pandemic on massage therapists in Australia and Canada: The reporting of a qualitative strand of a mixed methods study. J Bodyw Mov Ther 2023; 35:371-377. [PMID: 37330795 PMCID: PMC10148715 DOI: 10.1016/j.jbmt.2023.04.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 03/12/2023] [Accepted: 04/22/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION In both Australia and Canada, healthcare providers considered essential were allowed to operate during the COVID-19 pandemic. The impact of the global pandemic on professional identity included opportunities for role expansion, a focus on ethical principles and social accountability, and professional pride. These results were found only for those considered to be essential and do not likely resonate with those classified as non-essential, such as massage therapists, leaving a gap in understanding. MATERIALS AND METHODS This qualitative strand of a sequential explanatory mixed methods study used qualitative description. Individuals who expressed interest were purposefully selected, based on age, gender, type of practice, and experience with the four key phenomena of interest. Data collected through semi-structured interviews was analyzed using qualitative content analysis. Member checking enhanced the trustworthiness of the results. RESULTS Thirty-one (16 Australian and 15 Canadian) participants were interviewed. The main theme described was the pandemic paradox. At some point during the pandemic, most participants were labelled by government agencies as a non-essential service. However, participants reported feeling both essential and non-essential. Two subthemes were also described: factors contributing to creating the paradox and consequences of the paradox. CONCLUSION A number of pre-existing factors around professional identity, such as patient relationships combined with the conditions instituted to manage the COVID-19 pandemic included designating health care services as essential or non-essential, created the paradox experienced by respondents and the subsequent experience of moral distress. Further research into moral distress experienced by massage therapists is needed.
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Affiliation(s)
- Amanda Baskwill
- Faculty of Health Sciences and Wellness, Humber College, Canada; School of Health, Human and Justice Studies, Loyalist College, Canada.
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Australia; Camden and Campbelltown Hospitals, South Western Sydney Local Health District, Campbelltown, NSW, Australia
| | - Felicia Calleri
- Faculty of Health Sciences and Wellness, Humber College, Canada
| | | | | | - Sarah Fogarty
- School of Medicine, Western Sydney University, Australia
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Koonce M, Hyrkas K. Moral distress and spiritual/religious orientation: Moral agency, norms and resilience. Nurs Ethics 2023; 30:288-301. [PMID: 36536511 DOI: 10.1177/09697330221122905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nurses tasked with providing care which they perceive as increasing suffering often experience moral distress. Response to moral distress in nurse wellbeing has been widely studied. Less research exists that probes practicing nurses' foundations of moral beliefs. AIMS The purpose of this phenomenological study was to gain understanding of nurse meaning-making of morally distressing situations, with particular attention to ethical norms, moral agency and resiliency, and nurse religious/spiritual orientation. DESIGN This exploratory study employed semi-structured interviews using open-ended questions. Qualitative data analysis was assisted by MAXQDA software. PARTICIPANTS AND RESEARCH CONTEXT Nine pulmonary care nurses during COVID-19 in a tertiary care teaching hospital in the northeastern United States. ETHICAL CONSIDERATIONS The study was approved by the IRB. Participants were consented before the study and confidentiality was preserved. FINDINGS/RESULTS The study revealed three main themes of meaning-making, rooted in the identity of the "good nurse": Being true to one's own values, pursuing ideal patient care ("doing good"), and conforming to/challenging values of the system and culture. Tensions were found between (a) nurse's own values (b) duty to institutional norms and duty to nurse's personal code of ethics, and (c) perceptions of institutional support in response to nurse moral distress. Religion was described as a remote source of nurse moral values, among other sources. Spiritual practices were not experienced as sufficient in coping with moral distress at the bedside. CONCLUSIONS The study suggests nurses need more opportunities to engage in reflection on their practice and values. The findings also indicate need for accessible institutional supports for nurses experiencing moral distress and strategic use of chaplains in helping with moral distress. Further research is needed on the interplay of nurse spirituality, moral agency, and reflective practice in the face of morally challenging situations.
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Affiliation(s)
- Myrna Koonce
- Spiritual Care Coordinator for Palliative Medicine, 92602Maine Medical Center, Portland, ME, USA
| | - Kristiina Hyrkas
- Center for Nursing Research and Quality Outcomes, 92602Maine Medical Center, Portland, ME, USA
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Peng M, Saito S, Guan H, Ma X. Moral distress, moral courage, and career identity among nurses: A cross-sectional study. Nurs Ethics 2022; 30:358-369. [PMID: 36545793 DOI: 10.1177/09697330221140512] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Mengyun Peng
- Graduate School of Health Sciences, Okayama University, Japan
| | - Shinya Saito
- Graduate School of Health Sciences, Okayama University, Japan
| | - Hong Guan
- Department of Nursing, The Second Hospital of Dalian Medical University, China
| | - Xiaohuan Ma
- Department of Nursing, The Second People's Hospital of Dalian, China
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