Double distress: women healthcare providers and moral distress during COVID-19

Moral distress among maternal-fetal medicine fellows: a national survey study

BACKGROUND

Moral distress, or the inability to carry out what one believes to be ethically appropriate because of constraints or barriers, is understudied in obstetrics and gynecology. We sought to characterize moral distress among Maternal-Fetal Medicine (MFM) fellows using a standardized survey.

METHODS

We disseminated a national anonymized survey study of MFM fellows electronically regarding moral distress using a validated questionnaire with supplemental questions pertaining to specific challenges within MFM clinical care. Multivariable linear regression modeling was used to examine the association between abortion restrictions, maternal mortality, and moral distress, controlling for demographic variables. Thematic analysis was performed for the free text responses elaborating upon moral distress and grouped by thematic elements. We hypothesized that training in states with more abortion restrictions and higher maternal mortality would be associated with higher moral distress scores.

RESULTS

Among 245 total responses (61% response rate), 177 complete responses (44% complete response rate) were included for analysis. Most of our respondents identified as female (78.5%), White (71.8%), and training in urban programs (83.1%). 37.9% of respondents reported training in the Northeast, with the remainder of respondents evenly distributed across the United States. The mean score for the validated questions was 85.9 ± 48.8, with female gender identity associated with higher measures of moral distress on the validated portion of the questionnaire as compared to male gender identity (90.1 ± 49.2 vs. 70.4 ± 44.7, p < 0.05), whereas more advanced training was associated with higher measures of moral distress on the supplemental questions as compared to those less advanced in training (20.9 ± 11.8 vs. 28.5 ± 15.9 vs. 25.9 ± 15.6 for PGY-5 vs. PGY-6 vs. PGY-7 and PGY-8 combined, respectively, p < 0.05). After adjustment, higher measure of moral distress on the validated questionnaire was associated with training in states designated "Abortion restrictive" as compared to "Abortion most protective" (beta estimate 27.80 and p < 0.01). Of 34 free responses, 65% referred to limitations on abortion access and reproductive justice as causes of significant moral distress.

CONCLUSION

MFM fellows who identify as female reported higher measures of moral distress, as well as those training in states with more abortion restrictions. Among free text respondents, abortion restrictions underlie a significant proportion of moral distress.

An Intersectional Analysis of Moral Distress and Intention to Leave Employment Among Long-Term Care Providers in British Columbia

Objectives: In this study, we aimed to explore the relationship between intersectional inequities and moral distress among those working in Long-Term Care (LTC) in British Columbia, Canada. Methods: This was a cross-sectional and retrospective study. We assessed moral distress, of 1678 respondents, using a modified Moral Distress Scale, and an equivalent distress mitigation score, at the intersections of gender and racial/ethnic identity. Then, we explored which worker attributes were more predictive of intention to leave work. Results: We found notable difference in experiences of moral distress across intersecting identities, including high moral distress scores among Indigenous men and women, and white women. Significant differences in mitigation scores were also found by intersectional identities. Discussion: Moral distress was the most important predictor of intention to leave work. The differences across racial and gender identity groups suggest the need for tailored interventions to address moral distress among LTC providers.

Moral distress and protective work environment for healthcare workers during public health emergencies

BACKGROUND

Public health emergencies, such as the Covid-19 pandemic, put great pressure on healthcare workers (HCW) across the world, possibly increasing the risk of experiencing ethically challenging situations (ECS). Whereas experiencing ECS as a HCW in such situations is likely unavoidable, mitigation of their adverse effects (e.g., moral distress) is necessary to reduce the risk of long-term negative consequences. One possible route of mitigation of these effects is via work environmental factors.

OBJECTIVES

The current study aimed to examine: [1] risk factors associated with ECS among HCW [2], intensity of moral distress associated with ECS across various occupational factors (i.e., profession, degree of exposure to patients with Covid-19), and [3] the impact of work environmental factors on this association, in a sample of HCW during the pandemic.

METHODS

We employed multiple logistic and linear regression to self-report data from 977 HCWs at four Norwegian hospitals responding to a survey at the fourth wave of the pandemic.

RESULTS

About half of HCW in this study had experienced ECS during the pandemic, and levels of moral distress associated with such were higher than in previous studies using similar assessment methods. Younger age, female sex, geographical work area (mid-north of Norway), and profession (nurse) were all associated with higher odds (range of OR: 1.30-2.59) of experiencing ECS, as were direct contact with patients with Covid-19. Among those participants who reported that they had experienced ECS during the pandemic, moral distress levels when recalling those situations were moderate (Mean 5.7 on a 0-10 scale). Men reported somewhat lower intensity of moral distress (partial eta squared; ηp2 = 0.02). Reporting a manageable workload (ηp2 = 0.02), and greater opportunity to work according to best practice (ηp2 = 0.02), were associated with lower levels of moral distress.

CONCLUSIONS

Our findings suggest that moral distress could potentially be mitigated on an organizational level, particularly by focusing on ensuring a manageable workload, and an ability to work according to best practice. To build sustainable healthcare systems robust enough to withstand future public health emergencies, healthcare organizations should implement measures to facilitate these aspects of HCWs' work environment.

Moral distress related to paid and unpaid care among healthcare workers during the COVID-19 pandemic

While there is growing literature on experiences of healthcare workers and those providing unpaid care during COVID-19, little research considers the relationships between paid and unpaid care burdens and contributions. We administered a moral distress survey to healthcare workers in Canada, in 2022, collecting data on both paid and unpaid care. There were no significant differences in the proportion of participants providing unpaid care by gender, with both genders equally affected by certain responsibilities such as reduced contact with family/loved ones. However, men were significantly more distressed about specific unpaid care responsibilities. Unpaid care was not significantly associated with differences in intention to leave work. At work, women were significantly more concerned about patients unable to see family, while men were distressed by others mistreating COVID patients. This study enhances understanding of paid and unpaid care relationships, particularly during crises, and proposes an innovative method for assessing unpaid care burdens.

Moral distress, coping mechanisms, and turnover intent among healthcare providers in British Columbia: a race and gender-based analysis

BACKGROUND

This study explores intersectionality in moral distress and turnover intention among healthcare workers (HCWs) in British Columbia, focusing on race and gender dynamics. It addresses gaps in research on how these factors affect healthcare workforce composition and experiences.

METHODS

Our cross-sectional observational study utilized a structured online survey. Participants included doctors, nurses, and in-home/community care providers. The survey measured moral distress using established scales, assessed coping mechanisms, and evaluated turnover intentions. Statistical analysis examined the relationships between race, gender, moral distress, and turnover intention, focusing on identifying disparities across different healthcare roles. Complex interactions were examined through Classification and Regression Trees.

RESULTS

Racialized and gender minority groups faced higher levels of moral distress. Profession played a significant role in these experiences. White women reported a higher intention to leave due to moral distress compared to other groups, especially white men. Nurses and care providers experienced higher moral distress and turnover intentions than physicians. Furthermore, coping strategies varied across different racial and gender identities.

CONCLUSION

Targeted interventions are required to mitigate moral distress and reduce turnover, especially among healthcare workers facing intersectional inequities.

Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies

OBJECTIVE

At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions.

METHODS

A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic.

RESULTS

Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change.

CONCLUSION

This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.

Exploring feminist political economy and feminist critical discourse analysis as methodologies in critical nursing research

AIMS

This paper explores two critical feminist methodologies for nursing research: feminist political economy and feminist critical discourse analysis. The aim was to appreciate varied methodological approaches available for nurses to understand complexities in healthcare environments, above and beyond socially normative ways of knowing.

DESIGN

Discursive paper.

DATA SOURCES

Published articles from nursing databases (CINAHL and ProQuest; no date restrictions) and interdisciplinary databases (Women's Studies International, Sociological Abstracts and Ovid MEDLINE; publication dates between 2017 and 2022).

METHODS

A discursive paper exploring and critically synthesizing the literature on feminist political economy and feminist critical discourse analysis to demonstrate how each methodological approach can be used in nursing.

RESULTS

The findings of this discursive paper suggest there is an opportunity to draw on interdisciplinary studies for creative insights into how these methodologies may be helpful for nurses' scholarship and programmes of research. Although few nursing studies explicitly name a feminist political economy or feminist critical discourse analysis approach, several studies apply principles of these methodological approaches.

CONCLUSION

There is an opportunity for these methodologies to be applied within the same project when there is a fit between the research questions and aims of both methodologies (studies where notions of gender and power are considered central and there are potential insights from exploring social progress, structures and the material, along with the social relations of discourses).

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Feminist political economy and feminist critical discourse analysis offer novel options for methodological analyses.

IMPACT

Application of these methodologies may benefit critical nursing scholars looking for diverse critical methodological avenues to explore and to broaden nursing's methodological toolbox towards meeting social justice aims.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Two cases of nursing older nursing home residents during COVID-19

INTRODUCTION

Two ethical challenges of nursing home nurses during the COVID-19 pandemic in Sweden are discussed in this paper.

BACKGROUND

Historically, the nurse's primary concern is for the person who is ill, which is the core of nurses' moral responsibility and identity. In Sweden, person-centered care is generally deemed important in nursing older nursing home residents.

OBJECTIVE

To chart moral responsibilities of nursing home nurses in two cases involving older residents during the COVID-19 pandemic in Sweden.

METHODS

We used Margaret Urban Walker's framework for moral responsibilities and the International Council of Nurses (ICN) code of ethics for nurses (2021) for our normative analysis.

ETHICAL CONSIDERATIONS

Written and verbal consent was obtained before the interviews, and information was given that participation was entirely voluntary and possible to cancel at any time before the work was published. The Swedish Ethical Review Agency gave an advisory opinion stating that there were no ethical objections to this research project (Dnr. 2020-05649).

FINDINGS

Case #1: a palliative older nursing home resident who was coercively tested for COVID-19, and case #2: a COVID-19-infected resident with dementia who was isolated using sedation. The decision that was finally made in the respective case was analyzed in the light of either consequentialist/utilitarian or non-consequentialist/deontological reasons.

DISCUSSION

Empowerment of nurses as moral agents is required for the application of practical wisdom in the balancing of different care relationships (responsibilities), moral identities (professional virtues), and competing moral values. This requires resources and opens possibilities for profound ethical reflection in nursing education and at work.

CONCLUSION

During the COVID-19 pandemic, the moral and professional responsibility of nursing home nurses to deliver person-centered care was sometimes problematically abandoned in favor of a more utilitarian manner of ethical decision-making.

Women on the frontline: exploring the gendered experience for Pacific healthcare workers during the COVID-19 pandemic

Background

Women comprise 90% of patient-facing global healthcare workers (HCWs), yet remain underpaid, undervalued, and under-represented in leadership and decision-making positions, particularly across the Pacific region. The COVID-19 pandemic has exacerbated these health workplace inequalities. We sought to understand Pacific women HCWs experience from the COVID-19 frontline to contribute to policies aimed at addressing gendered gaps in regional health systems.

Methods

Our interpretative phenomenological study used critical feminist and social theory, and a gendered health systems analytical framework. Data were collected using online focus groups and in-depth interviews with 36 Pacific regional participants between March 2020 and July 2021. Gender-specific content and women's voices were privileged for inductive analysis by Pacific and Australian women researchers with COVID-19 frontline lived experience.

Findings

Pacific women HCWs have authority and responsibility resulting from their familial, biological, and cultural status, but are often subordinate to men. They were emancipatory leaders during COVID-19, and as HCWs demonstrated compassion, situational awareness, and concern for staff welfare. Pacific women HCWs also faced ethical challenges to prioritise family or work responsibilities, safely negotiate childbearing, and maintain economic security.

Interpretation

Despite enhanced gendered power differentials during COVID-19, Pacific women HCWs used their symbolic capital to positively influence health system performance. Gender-transformative policies are urgently required to address disproportionate clinical and community care burdens and to protect and support the Pacific female health workforce.

Funding

Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting

Background: When exposed to events that transgress one's moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting.Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity.Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect.Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 'perceived transgressions by others'; Factor 2 'perceived transgressions by self'; and Factor 3 'perceived betrayals by others'. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout.Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.