When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates

Moral distress among infection prevention and control professionals: A scoping review

BACKGROUND

The COVID-19 pandemic highlighted the vital role of Infection Prevention and Control Professionals (IPCPs) in safeguarding public health. Amid rapidly evolving guidelines, critical personal protective equipment shortages, and surging workloads, IPCPs encountered unprecedented moral and ethical dilemmas. However, their experiences, ethical challenges, and the resulting moral distress remain understudied.

METHODS

A scoping review following Arksey and O'Malley's methodology was conducted to examine current research on ethical challenges and moral distress among IPCPs. Searches in CINAHL, MEDLINE via OVID, Emcare, Scopus, and Korea Citation Index yielded two extracted articles.

RESULTS

Common themes included high workload, increased recognition, pressure to deliver accurate and timely information, need for peer support, and evidence-based practice. Differences in nationality, role discretion, and administrative systems led to varied experiences. District Medical Officers in Norway experienced more decision-making responsibilities and resulting ethical dilemmas in the context of broader communities and municipalities. The experiences of IPCPs were confined to their respective healthcare facilities.

CONCLUSION

There is a dearth of available research reporting the moral distress experienced by IPCPs whilst there is a plethora for those seen as "frontline" workers. Given the integral decision-making and implementation roles of these health professionals, and the burdens of ethical dilemmas they experienced in pandemic preparedness and response, further research is imperative to inform strategies to build moral resilience in the future.

Perceiving Ethical Discomfort Triggered by Situations that Resist Meaning in Community Mental Health Settings: A Grounded Theory

Community mental health care is a practice setting conducive to the emergence of special situations since the intervention takes place in the client's living environment, a context fraught with multiple and often unpredictable events and triggers. In addition, the healthcare workers are often alone in making decisions. This can lead to a persistent feeling of discomfort when the situation can be seen from several different angles and the healthcare workers find it difficult to make the right decision or are uncomfortable with the consequences of a decision they must make. This is the phenomenon of ethical discomfort. The aim of this study was to develop a grounded theory to better understand the relationships between ethical discomfort situations, their impact on lived experience by healthcare workers, and the mental processes and strategies employed by community mental health workers. We used a constructivist grounded theory methodology and conducted focus group interviews with five rural and urban community mental health teams. Our findings describe the context and process surrounding the identification of ethical discomfort by community mental health workers. Strategies such as dialogue with oneself, colleagues, or clients were helpful in deepening ethical reflection and alleviating ethical discomfort. Future research on ethical issues in community mental health care could help to develop ethical support interventions adapted to this mental health care context.

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.

Ethical reflections of healthcare staff on 'consentless measures' in somatic care: A qualitative study

BackgroundMany patients in medical wards lack decision-making capacity and cannot provide valid consent. As a result, nurses and other healthcare professionals often face a dilemma: whether to neglect the medical needs of such patients, or provide healthcare interventions without obtaining valid consent. Previous studies have indicated that many interventions are provided without consent; however, there is insufficient knowledge about how staff in this context reason about the ethical dilemmas they encounter.AimTo explore the ethical reasons provided by nurses and other healthcare professionals in medical wards for and against providing healthcare interventions without patients' consent.Research designThe study employed a qualitative explorative design. Eight focus group interviews were held with 37 staff across five different professions, mainly nurses, at two Swedish hospitals. The material was subjected to qualitative analysis, following a Reflective Thematic Analysis framework.Ethical considerationsEthical approval for this study was obtained from the Swedish Ethical Review Authority. All participants were informed orally and in writing about the study's aims and its voluntary nature. No sensitive personal information was registered. Participants provided their oral consent to participate before the interviews took place.Findings/ResultsThematic analysis resulted in four main themes: Coercion is a bad word; Reasons to accept coercion; Coercion is part of ward culture, and Unacceptable coercion.ConclusionsParticipants overwhelmingly supported the current use of 'consentless measures' at the investigated wards. Most situations described either needed no justification, according to participants, or could be easily justified by reference to the benefit of the patient, the patient's poor decision-making capacity, or the benefit of others. A range of implicit, contextual, and institutional justifications were also given. Suboptimal ward culture was considered a prime driver of consentless measures and a force that compromises nurses' agency in the patient encounter.

Moral Distress and the Cost of Caring Amongst Medical Oncologists in Singapore

BackgroundMoral distress (MD), the notion of not being permitted to act in a morally and ethically correct manner, is evident amongst oncologists caring for terminally ill patients. Oncologists often contend with complex decisions, such as withholding treatment and managing family distress. Sociocultural and individual considerations also influence an oncologist's perception of MD, which can vary in severity due to changing ethical, practical, clinical, moral and professional considerations and shifting contextual circumstances. Their impact compromises an oncologist's wellbeing, patient outcomes and care of their family. Recent data suggests long-term consequences to MD and alludes to a broader cost of caring that encompasses compassion fatigue, vicarious trauma, secondary traumatic stress and burnout.MethodsThis study aims to determine how oncologists in Singapore experience MD and the costs of caring through secondary analysis of interviews with 12 oncologists.ResultsAnalysis of the interview transcripts revealed the following domains: 1) sources of MD; 2) sources of the costs of caring; and 3) protective factors.ConclusionThis secondary analysis of Singaporean oncologists suggests that MD is not frequently an isolated experience; rather, it leads to growing distress amongst oncologists-contributing to a wider cost of caring. This then impacts oncologists' decisioning, actions, practice and career trajectories. Longitudinal structured training, establishing personalised support for all oncologists and creating a safe working environment supported by the host organisation are thus critical to ensure sustainable practice.

Ethical dilemmas and decision-making in emergency and critical care nursing in Western Amhara region, Northwest Ethiopia: a multi-method qualitative study

BACKGROUND

Ethical dilemmas in emergency and critical care nursing often involve complex decision-making that impacts patient outcomes, emotional well-being of healthcare providers, and team dynamics. Understanding these dilemmas and the decision-making processes involved is crucial for improving nursing practices and patient outcomes in this context.

OBJECTIVE

This study aims to explore the ethical dilemmas and decision-making processes of emergency and critical care nurses, using the Four Box. Method ethical decision-making framework.

METHODS

A multi-method qualitative approach was employed, incorporating in-depth individual interviews (IDI), focus group discussions (FGD), and case studies to capture diverse perspectives. Data were collected from 28 nurses working in emergency and critical care settings at Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital through purposive sampling. The interviews and focus groups were audio recorded, transcribed verbatim in Amharic, translated into English, and entered into OpenCode software for analysis. Inductive thematic analysis method was applied to analyze the data.

RESULTS

The study revealed several key ethical dilemmas faced by nurses, including balancing patient autonomy with beneficence, and the allocation of limited resources during crises, opioid administration for pain management vs. respiratory depression, and conflicts regarding informed consent. Nurses reported emotional and professional impacts from these dilemmas, contributing to moral distress, burnout, and ethical fatigue. Nurses emphasized the importance of interdisciplinary collaboration and structured decision-making frameworks to navigate these challenges. However, the lack of consistent access to ethics consultations and peer support during critical moments was noted as a significant barrier.

CONCLUSION AND RECOMMENDATION

Nurses encounter complex ethical dilemmas that impact their emotional well-being and job satisfaction. Effective decision-making requires applying ethical principles, adhering to guidelines, and consulting peers. The study reveals the need for improved support systems, including more frequent and comprehensive ethics training, better access to ethics consultations, and structured frameworks to guide decision-making in high-pressure situations.

CLINICAL TRIAL REGISTRATION

The study is not a clinical trial, a clinical trial number is not applicable.

Newly graduated nurses' experiences of moral distress during transition process: a convergent mixed methods study

BACKGROUND

Newly graduated nurses are particularly vulnerable to moral distress due to limited experience, low self-confidence, and inadequate ethical knowledge, which impact their ability to make and act on ethical decisions. This study aims to describe their moral distress experiences during the transition to professional practice and identify predictive factors affecting moral distress levels.

METHODS

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 a semi-structured questionnaire. The analysis was conducted separately and then integrated. In the quantitative part of the study, 205 new nurses with 1-18 months of working experience were recruited, and 25 new nurses were recruited in the qualitative part.

RESULTS

Gender, type of hospital, experience time, caregiver and manager role level, and subjective perception of levels were significant predictors of moral distress. Qualitative data revealed four main themes: (1) causes of moral distress, (2) effect of moral distress, (3) coping with moral distress, and (4) suggestions for reducing moral distress.

DISCUSSION

The moral distress experienced by newly graduated nurses may become more pronounced during the transition to professional life. During this period, lack of experience, low self-confidence, and insufficient ethical knowledge can increase moral distress and affect future experiences by making it difficult to make and implement ethical decisions.

CONCLUSIONS

This study showed that individual, organizational, and systemic factors influence moral distress in new graduate nurses. It highlights that ethical challenges in developing professional identity are closely tied to organizational structure and systemic regulations, emphasizing the need for individual support and improvements in education and organizational systems to reduce moral distress.

CLINICAL TRIAL NUMBER

Not applicable.

The influence of the hidden curriculum on the risk of burnout in junior doctors in a palliative medicine rotation - a qualitative exploratory study

BACKGROUND

Palliative Care (PC) provides person-centred care for patients with life-limiting diseases and their families. Studies have shown that healthcare professionals delivering PC are predisposed to moral distress and burnout due to constant exposure to death and dying and aspects of the hidden curriculum (HC) through which culture and values are transmitted implicitly. However, there are limited studies focusing on the latter through the lens of junior doctors. Using the Ring Theory of Personhood (RToP) and the Krishna-Pisupati Model (KPM), which categorize and map conflicts between personal and professional values, beliefs, and principles within the four domains of personhood, this study investigates the impact of palliative care experiences on the risk of burnout in junior doctors.

METHODS

This qualitative exploratory study was conducted at the Division of Supportive and Palliative Care in the National Cancer Centre Singapore, involving medical residents who had completed at least one month with the division between 2020 and 2022. 13 participants were recruited for individual semi-structured interviews carried out by an independent research assistant. Acknowledging HC and burnout as sociocultural constructs, we adopted a constructivist ontological position and a relativist epistemological lens to guide thematic analysis of the data.

RESULTS

The themes identified were: (1) The Nature of PC (2), Moral Distress, and (3) Impact of Environment on Wellbeing. Junior doctors saw the value of the philosophy of care in PC and felt compelled to adopt values espoused by the discipline. However, compounded by consistent exposure to death and dying and limitations to manpower and time, elements of the HC, such as staff support measures, proved to be significant stressors-contributing to burnout and moral distress.

CONCLUSION

This is the first study on the effects of the HC on burnout for junior doctors in a PC rotation. It provides unique insights into the impact of complex clinical, personal, social, ethical and organizational factors on burnout and suggests that all factors need to be addressed in tandem for any attempts at staff support to be successful. This study can guide current and future research and programs that support wellbeing for junior doctors.

Developing an evidence-and ethics-informed intervention for moral distress

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic's trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach to develop a moral distress intervention-proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness.

Trainee resistors: Have our students become our teachers?

The authors urge medical education to move beyond teaching social determinants, advocating for active resistance to systemic injustices and a more politically engaged and justice‐oriented approach to healthcare training.

"Definitely a Dark Time:" professional and ethical issues in post-acute care physical therapy during the COVID-19 pandemic

BACKGROUND

Disproportionate effects of the SARS-CoV-2 (COVID-19) pandemic on older adults in post-acute care settings created many professional and ethical challenges for patients and healthcare providers.

OBJECTIVE

The purpose of this study was to examine the professional and ethical issues of physical therapists (PTs) and physical therapist assistants (PTAs) in providing facility-based post-acute care in residential settings (skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals) during the COVID-19 pandemic.

METHODS

A qualitative descriptive research design was used to explore professional and ethical issues during the COVID-19 pandemic. PTs and PTAs described their experiences during semi-structured interviews conducted virtually. Interview data was analyzed with reflexive thematic analysis.

RESULTS

Thematic analysis produced 4 themes: facility-wide battle against infection and death, doing the best you can to provide care amidst COVID-19 constraints, promoting ethical good and doing the right thing, and a dark intense time.

CONCLUSIONS

Professional and ethical constraints on providing care faced by PTs and PTAs during the COVID-19 pandemic can inform current and future clinical practice. Although some of the challenges faced by PTs and PTAs were unique to COVID-19, many problems represent preexisting systemic and organizational issues that were exacerbated by the pandemic.

Investigating Moral Distress in Clinical Research Professionals-A Deep Dive into Troubled Waters

Moral distress occurs when professionals are constrained from taking what they believe to be ethically appropriate actions or are forced to take actions they believe are ethically inappropriate, challenging their professional identities and representing systems-level issues within organizations. Moral distress has been recognized in a variety of health care-related fields; however, the phenomenon is still comparatively unexplored among clinical research professionals (CRPs). In this qualitative study, we interviewed ten CRPs to unearth root causes of moral distress in this ethically unique profession. Four themes emerged from the data as contributors to moral distress: commodification of research; concern for research participants; compromised science; and structures of hierarchy. The experience of racism as a source of moral distress is also explored. The findings of this study indicate that the existence of moral distress in clinical research is troubling not only for the welfare of CRPs but also for the greater clinical research enterprise.

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

PATIENT OR PUBLIC CONTRIBUTION

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

Willing but Unable: Moral Distress and Burnout in Italian Veterinarians Working with Companion and Farm Animals

Veterinarians face ethical challenges during their careers, but despite evidence of work-related stress and burnout in veterinarians, moral distress has been poorly investigated. Using an online survey, professional experience, moral distress, and burnout were investigated in 704 Italian veterinarians caring for companion animals, farm animals, or both. The reliability of the moral distress questionnaire was optimal, and Factor analysis identified four factors for moral distress: I. Conflict with owner/farmer; II. Relationships with colleagues/superiors; III. Legal context/unsupportive Professional Institutions; IV. Unshared requests for euthanasia. Veterinarians reported rather low levels of moral distress but high levels of work-related stress/anxiety and a decline in empathy over time, mainly toward owners/farmers. More than 50% of veterinarians reported medium/high levels of burnout, and client-related burnout was significantly higher than animal-related burnout. Levels of work-related stress, moral distress, and burnout were higher in women, and experience exerted a protective effect. Moral distress was positively correlated with emotional exhaustion and depersonalization and, to a lesser extent, lower professional fulfillment. The relatively low level of moral distress that emerged in the study needs further investigation, especially considering the high levels of work-related stress and anxiety reported by veterinarians. Women's greater sensitivity to moral distress and burnout should not be overlooked given the progressive feminization of the veterinary profession worldwide.

A qualitative study examining stressors among Respiratory Therapists in Ontario amidst the COVID-19 pandemic

Health care systems were subjected to an unprecedented surge of critically ill patients with the coronavirus disease 2019 (COVID-19), which required management by Respiratory Therapists (RTs). Despite the high level of burnout reported in this health care professional group, we have limited knowledge about the lived experience of RTs during the pandemic. This study aims to examine the impact of COVID-19 on RTs in Ontario, Canada. We conducted a qualitative exploratory, descriptive study by conducting virtual semi-structured interviews and focus groups with RTs between March 2023 and June 2023. Two coders analyzed the data using thematic analysis. Twenty-seven RTs participated in the study, with the majority being female (n = 25), averaging 16.4 years of practice (range 4 to 36 years), primarily in acute care settings (n = 23). We identified four themes and lessons learned from the perspective of RTs: (1) Working in the shadow and suffering in silence reflecting varying perceptions of recognition; (2) Flying blind amidst the buzz reflecting the rapid pace of changing policies and practices as COVID-19 gained global attention; (3) Putting out fires in the face of overflowing hospitals reflecting increased workload and staffing issues; and (4) Managing tensions, both external and internal reflecting how RTs coped with distressing workplace situations and their mental well-being. Finally, lessons learned from the RTs include 1) Mobilizing early and consistently during an emergency, which addresses staff concerns; 2) Prioritizing and investing in the mental health and well-being of RTs; 3) Implementing strategies to retain experienced staff in healthcare; and 4) Involving RTs in leadership discussions. The COVID-19 stressors of RTs have illuminated the detrimental impact of the pandemic on this understudied health care profession. With this knowledge, targeted interventions can be developed to address RT recognition and staff retention and provide mental health support.

"It's Traumatic for All of Us": A Qualitative Analysis of Providers Caring for Seriously Ill Veterans With Surgical Conditions

Objective

We aimed to characterize sources of moral distress among providers in the context of surgery.

Background

Moral distress is defined as psychological unease generated when professionals identify an ethically correct action to take but are constrained in their ability to take that action. While moral distress has been reported among healthcare providers, the perspectives of providers working in surgery specifically are not often explored and reported. Our study was developed from an overarching effort to investigate end-of-life care for seriously ill patients with surgical conditions.

Methods

Using convenience sampling, we conducted 48 semistructured interviews with providers who provide high-intensity care (eg, surgeons, anesthesiologists, intensivists, and midlevel providers) for seriously ill patients with surgical conditions across 14 Veterans Affairs hospitals. Interviews were analyzed iteratively using thematic content analysis.

Results

Providers described clinical encounters that generated moral distress while caring for seriously ill patients with surgical conditions: (1) difficulties in conflict resolution with and among patients and families; (2) specific types of patients or situations; (3) systemic factors hindering appropriate end-of-life care; (4) surgical culture and expectations of the surgeon's role.

Conclusions

Providers caring for seriously ill patients with surgical conditions report emotions and reactions consistent with moral distress. Our study highlights important triggers for providers and hospital systems to identify and address throughout a surgical provider's training and career.

Physiotherapists' moral distress: Mixed-method study reveals new insights

BACKGROUND

Moral distress is a well-recognized term for emotional, cognitive, and physical reactions of  professionals, when facing conflicts between perceived obligations and institutional constraints. Though studied across medical roles, limited research exists among physiotherapists.

RESEARCH QUESTION

What factors contribute to Moral distress among physiotherapists and how do they cope?

OBJECTIVES

To develop and test a multifaceted model of Moral distress and gain an in-depth understanding of the phenomena.

RESEARCH DESIGN

A 2017-2022 mixed-methods study: (1) Survey of 407 physiotherapists quantitatively testing a literature-based model analyzing relationships between Moral distress, Moral sensitivity, Locus of control, Self-efficacy, Ethical climate perceptions and demographics, analyzed by descriptive and inferential statistics, multiple comparisons and structural equation modelling (SPSS26, SAS, AMOS); (2) Semi-structured interviews with 21 physiotherapists examining Moral distress experiences using meticulous phenomenological analysis.

PARTICIPANTS AND CONTEXT

Israeli physiotherapists from various occupational settings recruited via professional networks.

ETHICAL CONSIDERATIONS

The Haifa University Ethics Committee authorized the study. Informed consent was obtained for the anonymous survey and before interviews regarding recording, and quote use.

FINDINGS

Quantitative results showed moderately high average Moral distress, significantly higher among women and paediatric physiotherapists, positively correlating with Moral sensitivity. Qualitative findings revealed intense emotions around Moral distress experiences, inner conflicts between care ideals and constraints, and coping strategies like reflective skills. Senior therapists, despite higher self-efficacy and moral sensitivity, still reported persistent high distress.

DISCUSSION

Moral distress has complex links with moral sensitivity, self-efficacy, perceived professional autonomy and organizational support. A renewed framework emerged explaining relations between moral distress and personal, professional and organizational factors.

CONCLUSIONS

Multidimensional insights help identify Moral distress causes and coping strategies among physiotherapists, advancing theory. Conclusions can shape ethics training programs and competencies.

Canadian intensive care unit nurses' responses to moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions

AIMS

To describe intensive care unit nurses' experiences of moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions.

DESIGN

Interpretive description.

METHODS

Data were collected with a purposeful sample of 40 Canadian intensive care unit nurses between May and September 2021. Nurses completed a demographic questionnaire, the Measure of Moral Distress-Healthcare Professionals survey and in-depth interviews. Quantitative data were analysed using descriptive statistics. Qualitative data were categorized and synthesized using reflexive thematic analysis and rapid qualitative analysis.

RESULTS

Half of the nurses in this sample reported moderate levels of moral distress. In response to moral distress, nurses experienced immediate and long-term effects across multiple health domains. To cope, nurses discussed varied reactions, including action, avoidance and acquiescence. Nurses provided recommendations for interventions across multiple organizations to mitigate moral distress and negative health outcomes.

CONCLUSION

Nurses reported that moral distress drove negative health outcomes and attrition in response to moral events in practice. To change these conditions of moral distress, nurses require organizational investments in interventions and cultures that prioritize the inclusion of nursing perspectives and voices.

IMPLICATIONS FOR THE PROFESSION

Nurses engage in a variety of responses to cope with moral distress. They possess valuable insights into the practice issues central to moral distress that have significant implications for all members of the healthcare teams, patients and systems. It is essential that nurses' voices be included in the development of future interventions central to the responses to moral distress.

REPORTING METHOD

This study adheres to COREQ guidelines.

IMPACT

What Problem did the Study Address? Given the known structural, systemic and environmental factors that contribute to intensive care unit nurses' experiences of moral distress, and ultimately burnout and attrition, it was important to learn about their experiences of moral distress and their recommendations for organizational mitigative interventions. Documentation of these experiences and recommendations took on a greater urgency during the context of a global health emergency, the COVID-19 pandemic, where such contextual influences on moral distress were less understood. What Were the Main Findings? Over half of the nurses reported a moderate level of moral distress. Nurses who were considering leaving nursing practice reported higher moral distress scores than those who were not considering leaving. In response to moral distress, nurses experienced a variety of outcomes across several health domains. To cope with moral distress, nurses engaged in patterns of action, avoidance and acquiescence. To change the conditions of moral distress, nurses desire organizational interventions, practices and culture changes situated in the amplification of their voices. Where and on Whom Will the Research Have an Impact on? These findings will be of interest to: (1) researchers developing and evaluating interventions that address the complex phenomenon of moral distress, (2) leaders and administrators in hospitals, and relevant healthcare and nursing organizations, and (3) nurses interested in leveraging evidence-informed recommendations to advocate for interventions to address moral distress. What Does this Paper Contribute to the Wider Global Community? This paper advances the body of scientific work on nurses' experiences of moral distress, capturing this phenomenon within the unique context of a global health emergency. Nurses' levels of moral distress using Measure of Moral Distress-Healthcare Professional survey were reported, serving as a comparator for future studies seeking to measure and evaluate intensive care unit nurses' levels of moral distress. Nurses' recommendations for mitigative interventions for moral distress have been reported, which can help inform future interventional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Strategies to mitigate moral distress as reported by eldercare professionals

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

'The Emperor's new clothes?' Healthcare professionals' perceptions of the nursing associate role in two UK National Health Service hospitals: A qualitative interview study

Background

The introduction of nursing associates in England in 2017 as a professional 'bridging' role aimed to mitigate chronic staffing shortages, enable career progression of healthcare assistants and release registered nurses to provide more complex care. Limited evidence exists about the alignment between the identity and purpose of nursing associate roles described by the UK independent regulator, the Nursing & Midwifery Council, and the expectations, obligations, and team dynamics encountered in practice.

Purpose

Investigate the perceptions of nursing associate roles through the views and experiences of role holders, registered nurses, and healthcare assistants.

Setting

Two British National Health Service (NHS) Hospital Trusts in London, England (UK).

Methods

For this registered service evaluation, data were collected via in-person, semi-structured interviews. Verbatim transcripts were coded inductively. An adapted framework analysis method, suitable for use with Excel, was applied to support the identification of cross cutting themes. We used the Standards for Reporting Qualitative Research checklist for reporting this study.

Results

Eleven registered nurses, five nursing associates, and five healthcare assistants participated. Their experiences seldom reflected the policy vision of the nursing associate role in practice. Several participants likened the nursing associate role to the fable of the 'Emperor's New Clothes' in which expectations and reality diverge. With this over-arching theme, four sub-themes were identified: (1) preparedness of organisational infrastructure to support this role; (2) credibility of the role in practice; (3) perceived organisational "blindness" to the ambiguities of the role and (4) increasing task orientation and segmentation in care delivery.

Conclusion

There is a discrepancy between the identity of the nursing associate role as imagined in the policy agenda and its reality in practice. There is a need for more protected and well-defined training, clear role boundaries, and accessible career progression pathways for nursing associates. Moreover, honest dialogue at an organisational and policy level must continue, so that the challenges and opportunities of the nursing associate role are properly realised.

Tweetable abstract

Emperor's new clothes! Experiences and views of new nursing associate roles in NHS (UK) acute hospitals @CarolynSpring3.

Multi-professional perspectives to reduce moral distress: A qualitative investigation

BACKGROUND

Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited.

RESEARCH OBJECTIVE

The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center.

PARTICIPANTS & RESEARCH CONTEXT

Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim.

RESEARCH DESIGN

Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the university and medical center institutional review boards.

FINDINGS

Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities.

CONCLUSION

Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Moral sensitivity and academic ethical awareness of nursing and medical students: A cross-sectional survey

BACKGROUND

Moral sensitivity and academic integrity discernment hold paramount importance for healthcare professionals. Owing to distinct undergraduate educational backgrounds, nurses and physicians may exhibit divergent moral perspectives, academic integrity cognisance, and moral sensitivity within clinical environments. A limited number of studies have investigated the disparities and congruencies pertaining to moral sensitivity and academic ethical awareness among nursing and medical students.

OBJECTIVE

The study compares moral sensitivity and academic ethical awareness of undergraduate nursing and medical students with and without clinical exposure.

RESEARCH DESIGN

A self-administered cross-sectional survey conducted from January to February 2022 was used to collect data from a medical school in Hong Kong.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 545 respondents, including 137 nursing students and 408 medical students, completed the questionnaire.

ETHICAL CONSIDERATION

Ethics approval of the study was obtained. Written consent was waived to maintain anonymity because completing the questionnaire was considered implied consent.

FINDINGS

Both groups of undergraduates demonstrated a high level of bioethics knowledge. In terms of academic integrity, medical students were found to have a less concerned attitude towards punctuality, attendance, and skipping classes. Regarding moral sensitivity, senior medical students with clinical experience put less emphasis on decision-making involving patient participation, while senior nursing students were more hesitant in withholding treatment for incompetent patients who refused treatment. Both nursing and medical students showed decreased moral sensitivity in the 'conflicts' domain with increased clinical exposure.

CONCLUSION

Study findings contribute to the discussion comparing the ethical attitudes of nursing and medical students. More effort should be made in nursing and medical education to promote practices in line with high academic integrity and to develop the ability to be morally sensitive in professional settings.

Navigating the Ethical Challenges of Clinical Decision-Making for Patients with Mental Illness Presenting with Self-Inflicted Burns

Complex ethical considerations can arise when patients with severe, persistent mental illness (SPMI) present with critical illness resulting from self-injury. This article presents 2 clinical cases in which a patient with SPMI was admitted with severe injuries following self-inflicted burns, with a substantial impact on their anticipated quality of life and challenges directing their medical care. In both cases, the medical teams held discussions with surrogate decision-makers in order to evaluate the patient's minimal acceptable quality of life and make medical decisions that best reflected the patient's voice and goals. These cases underscore the importance of advance care planning in SPMI, particularly the appointment of a surrogate decision-maker, and highlight the moral distress that can arise among surgical teams and trainees while caring for patients with illness resulting from self-harm. This article offers a framework for approaching decision-making in critical illness resulting from self-harm for patients with SPMI.

A Phenomenological Exploration of Physicians' Moral Distress: Situating Emotion Within Lived Experiences

PURPOSE

Physicians often experience moral distress from being prevented from taking what they believe to be the right course of action. Although causes and consequences of moral distress have been studied, little research offers insight into the significance of feeling morally challenged, especially in medicine. This study was undertaken to advance understanding of what physicians experience when encountering morally challenging situations and to examine how those experiences influence their interactions with the world of health care.

METHOD

Guided by hermeneutic phenomenology, the authors conducted semistructured interviews with purposefully sampled Canadian physicians from September 2022 to January 2023. Analysis used Van Manen's 6 activities of hermeneutic research and included "story crafting" to sharpen insights. Late in that process, Van Manen's "lived existentials" was determined to provide a strong framework for physicians' experiences of moral distress.

RESULTS

Of the 12 physicians interviewed, all experienced varied and long-lasting emotional reactions to morally challenging experiences. The emotions associated with moral distress, reported as inevitable, were experienced in ways that aligned with the lived existentials of body, space, time, and relations.

CONCLUSIONS

A richer understanding of physicians' lived experiences with moral distress can help mentors and educators more thoughtfully engage in conversations about it with colleagues and learners. This study highlights the core dimensions of moral distress through body, space, time, and relations, thereby providing a means to enrich discussion about emotions and their transformational power. Through such nuanced consideration, calls for emotional candor may be strengthened to enhance practice by acknowledging the scope of impact that efforts to deliver care are likely to provoke.

An exploratory examination of the symptoms of moral injury and posttraumatic growth in veterinary professionals following exposure to potentially morally injurious events

Through their occupational role, veterinary professionals are regularly exposed to potentially morally injurious events (PMIEs). These events can elicit negative (pathogenic) psychological outcomes of moral distress. However, PMIEs can also result in positive (salutogenic) outcomes of posttraumatic growth. Both outcomes are characterised by specific symptomology that is suggestive of a pathogenic or salutogenic trajectory. This study employed data from 194 veterinary professionals from Australia and New Zealand and sought to examine symptoms experienced by professionals following exposure to PMIEs. Respondents reported more symptoms of moral distress than posttraumatic growth following PMIE exposure. Negative symptoms included both affective and work-related factors including consideration of leaving the profession, while positive factors included increased confidence, personal growth, and staff cohesion. Potential factors contributing to the disparity in salutogenic and pathogenic outcomes are discussed. An integrated approach comprising both individual- and organisation-level factors is recommended to facilitate more salutogenic outcomes for veterinary professionals following PMIE exposure.

Moral distress in pediatric nurses: A scoping review protocol

INTRODUCTION

Recently, moral distress in pediatric nursing has gained academic attention, yet comprehensive literature reviews on this group are scarce.

AIMS

This study aims to offer a detailed overview of moral distress among pediatric nurses, focusing on understanding its characteristics, prevalence, underlying causes, and consequences on the quality of patient care.

METHODS

Employing a scoping review approach as recommended by the Joanna Briggs Institute, this study will systematically search through PubMed, Scopus, Web of Science, APA PsycInfo, and CINAHL databases using specific search strategies. Titles, abstracts, and full texts will be independently screened by two reviewers according to the eligibility criteria. Relevant data will be extracted, categorized, and subjected to narrative synthesis to draw comprehensive insights.

CONCLUSION

The anticipated findings of this study will shed light on the nature, frequency, and drivers of moral distress among pediatric nurses, along with its broader implications for healthcare practitioners, organizational practices, and patient care outcomes.

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.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Survey of Moral Distress and Self-Awareness among Health Care Professionals

Health care professionals experience moral distress due to challenging ethical decision-making during patient care. Self-awareness can be associated with moral distress. This study determined the levels of and relationship between moral distress and self-awareness of health care professionals. A convenience sample of physicians and nurses was recruited. Data were collected using the Moral Distress and Self-Awareness Scales. In total, 168 physicians and 201 nurses participated with a mean age of 30.54 ± 7.87 and clinical experience of 6.40 ± 6.22 years. Moderate levels of moral distress (127.07 ± 71.90) and high levels of self-awareness (70.20 ± 11.37) were found. A weak positive correlation was found between self-awareness and moral distress (r = 0.21, p < 0.001) and weak negative correlation between moral distress (r = - 0.115, p = 0.03) and age. Nurses were more self-aware, but no differences were observed in moral distress based on sex and clinical settings. A weak correlation between self-awareness and moral distress may suggest that self-awareness can increase intrapersonal tensions, contributing to distress. Further research is needed to support any conclusive relationship between moral distress and self-awareness.

Causes of moral distress among midwives: A scoping review

Numerous studies have evidenced moral distress among midwives; however, to date no research synthesis on causes of moral distress among midwives has been conducted. A scoping review was carried out to identify, comprehensively map, and categorize possible causes of moral distress among midwives, and to identify knowledge gaps. Six data bases were searched using Boolean logic. To be included, studies had to (a) present empirical findings on (b) causes of moral distress (c) among midwives (d) in English, German, French, or Italian. We included a final set of 43 studies. The vast majority of studies came from high-income countries (83.7%) and used a qualitative approach (69.8%); 48.8% of the studies were published in the past 5 years. Identified single reasons of moral distress were grouped into eight broader clusters, forming a coherent framework of reasons of moral distress: societal disregard, contemporary birth culture, resources, institutional characteristics, interprofessional relationships, interpersonal mistreatment of service users, defensive practice, and challenging care situations. These clusters mostly capture moral distress resulting from a conflict between external constraints and personal moral standards, with a smaller proportion also from an intraindividual conflict between multiple personal moral standards. Despite projected increases in demand for midwives, the midwifery workforce globally faces a crisis and is experiencing substantial strain. Moral distress further exacerbates the shortage of midwives, which negatively affects birth experiences and birth outcomes, ultimately rendering it a public health issue. Our findings offer points of leverage to better monitor and alleviate moral distress among midwives, contributing to reducing attrition rates and improving birth experiences and birth outcomes. Further research is essential to explore the issue of ecological moral distress, develop evidence-based interventions aimed at alleviating moral distress among midwives, and evaluate the effects of both individual and system-level interventions on midwives, intrapartum care, and service users' outcomes.

Nurses navigating moral distress, resilience, and team dynamics: A literature review

BACKGROUND

This manuscript explores the pervasive issue of moral distress among nurses and its impact on their well-being and professional satisfaction. Focusing on diverse factors contributing to moral distress, the review spans various experience levels and patient care settings.

METHOD

Utilizing integrative reviews and sourcing from PubMed, CINAHL, SCOPUS, PsycINFO, and ProQuest, the study synthesizes findings from studies worldwide. The conceptual framework by Whittemore & Knafl is employed to comprehensively analyze nurses' experiences.

RESULTS

Key factors were identified as contributing to moral distress, including concerns about care quality, team dynamics, and insufficient support. Interventions range from light-touch approaches like mentorship programs to resource-intensive strategies such as staff wellness initiatives. The impact of the COVID-19 pandemic on nurses' moral distress is also explored.

CONCLUSION

Moral distress in nurses leads to burnout and, in some cases, prompts professionals to leave the field. The study emphasizes the need for organizational-level initiatives, support networks, and interventions to address moral distress. Identified gaps in the literature underscore opportunities for future research to better prepare clinicians and advance understanding across experience levels and settings.

Moral distress from professionalism dilemmas and its association with self-rated professionalism behaviors among Chinese residents

OBJECTIVES

Residents inevitably witness or participate in a diverse range of professionalism dilemmas. However, few studies have focused on residents' moral distress from professionalism dilemmas and its relationship with residents' professionalism. This study aimed to understand the moral distress that Chinese residents may face after exposure to professionalism dilemmas and to examine the associations between moral distress and residents' perceived fulfillment of professionalism behaviors.

METHODS

We conducted a cross-sectional survey of residents from four standardized residency training bases in Liaoning Province, China, using stratified cluster sampling. A checklist of professionalism dilemmas, the Moral Distress Scale, and the Behavior-based Medical Professionalism Inventory were used to assess residents' moral distress from professionalism dilemmas and their perceived fulfillment of professionalism behaviors. Descriptive statistics, non-parametric tests, multiple linear regressions, and binary logistic regressions were used to analyze the data.

RESULTS

A total of 647 (81.1%) residents effectively completed the survey. The proportion of residents suffering from moral distress ranged from 58.4 to 90.6% for different professionalism dilemmas. As the number of professionalism dilemmas associated with moral distress increased, residents reported lower fulfillment of professionalism behaviors (β < 0, p < 0.05). Compared with residents with no distress, residents suffering from distress reported lower fulfillment of professionalism behaviors (OR < 1, p < 0.05). Among residents suffering from distress, as the distress intensity increased, residents reported higher fulfillment of professionalism behaviors (OR > 1, p < 0.05).

CONCLUSIONS

Residents suffered a wide range of moral distress from professionalism dilemmas, and residents with moral distress reported lower fulfillment of professional behaviors. A responsive reporting system for residents and reflection on role modeling may help residents cope with the negative effects of moral distress and professionalism dilemmas.

Deontological Guilt and Moral Distress as Diametrically Opposite Phenomena: A Case Study of Three Clinicians

Feelings of guilt are human emotions that may arise if a person committed an action that contradicts basic moral mores or failed to commit an action that is considered moral according to their ethical standards and values. Psychological scholarship distinguishes between altruistic guilt (AG) and deontological guilt (DG). AG results from having caused harm to an innocent victim, either by acting or failing to act, whereas DG is caused by violating a moral principle. Although physicians may be expected to experience frequent feelings of guilt in their demanding and intensive work, it is surprising to find that this issue has not been explored in the professional literature on medical ethics. To that end, we conducted a qualitative study that included personal in-depth interviews with Sunni Muslim gynaecologists. These doctors provide underground infertility care and perform religiously forbidden treatments involving sex selection and gamete donation. They opened their hearts and spoke about the emotionally taxing pangs of conscience they suffer. Analysing their narratives led us to characterize their feelings of guilt as DG. We discuss the causes for their plight and the way they cope with it, compare DG to the concept of moral distress, and call for future research on clinicians' feelings of guilt and pangs of conscience.

From moral distress to resilient ethical climate among general practitioners: Fostering awareness. A qualitative pilot study

BACKGROUND

Moral distress in and ethical climate of health care institutions are highly intertwined subjects and have been linked to various quality of care indicators as well as job turnover intentions among health care professionals. Predominantly, both phenomena have been studied in intensive care, palliative and in-hospital settings. We aimed to explore the experience of moral distress by general practitioners (GPs), the role of ethical climate in GP moral distress and how ethical climate and moral distress can result in moral resilience in general practice.

METHODS AND FINDINGS

Between April and October 2021, we interviewed 13 doctors active in general practice in Flanders, Belgium, through semi-structured interviews. Data were processed and analysed using the Qualitative Analysis Guide of Leuven (QUAGOL). Most GPs had ample experience with morally distressing situations. Causes, determinants, and consequences do not differ significantly from other care settings. Moral distress can arise from conflicting views of good care, communication problems, and impending harm to third parties. We detected determinants of moral distress on micro-, meso- and macrolevels. GPs associate moral distress with job turnover and emotional, physical, existential, and quality of care effects. Several malleable factors can contribute to resilient ethical climates. This requires acquisition of vocabulary, skills, and knowledge.

CONCLUSIONS

Moral distress and ethical climate are important emerging themes for GPs. This research identifies determinants and effects of moral distress and ethical climate in primary care and could help GPs leverage moral distress experiences into morally resilient primary care through multiple suggested strategies.

Why Are Healthcare Providers Leaving Their Jobs? A Convergent Mixed-Methods Investigation of Turnover Intention among Canadian Healthcare Providers during the COVID-19 Pandemic

BACKGROUND

Staffing shortages across the healthcare sector pose a threat to the continuity of the Canadian healthcare system in the post-COVID-19 pandemic era. We sought to understand factors associated with turnover intention as well as Canadian healthcare providers' (HCPs) perspectives and experiences with turnover intention as related to both organizational and professional turnover.

METHOD

A convergent questionnaire mixed-methods design was employed. Descriptive statistics and ordinal logistic regressions were used to analyze quantitative data and ascertain factors associated with turnover intention. Thematic analysis was used to analyze qualitative open-field textbox data and understand HCPs' perspectives and experiences with turnover intention.

RESULTS

Quantitative analyses revealed that 78.6% of HCPs surveyed (N = 398) reported at least a 25% turnover likelihood regarding their organization, with 67.5% reporting at least a 25% turnover likelihood regarding their profession. Whereas regression models revealed the significant impact of years worked, burnout, and organizational support on turnover likelihood for organizations, age, sex, burnout, and organizational support contributed to the likelihood of leaving a profession. Patterns of meaning drawn from participants' qualitative responses were organized according to the following four themes: (1) Content to stay, (2) Drowning and no one cares, (3) Moral stressors, and (4) Wrestling with the costs and benefits.

CONCLUSIONS

Many HCPs described weighing the costs and benefits of leaving their organization or profession during the COVID-19 pandemic. Although challenging working conditions, moral stressors, and burnout may play a significant role in HCPs' experiences of turnover intention, there is ample room to intervene with organizational support.

Augmentative and Alternative Communication Interventions in Critical and Acute Care With Mechanically Ventilated and Tracheostomy Patients: A Scoping Review

PURPOSE

Communication with nonspeaking patients is a critical challenge of person-centered care. This scoping review aimed to map the literature on augmentative and alternative communication (AAC) interventions for nonspeaking mechanically ventilated and tracheostomy patients in critical and acute care settings.

METHOD

Electronic database, ancestry, and forward citation searches were conducted using eligibility criteria established a priori. Data were extracted, synthesized, and summarized according to scoping review methodology. Studies were categorized by type of intervention and summarized in terms of purpose, participants, design, quality appraisal (including validity and reliability of selected efficacy measures), and efficacy.

RESULTS

Small-to-large treatment effect sizes indicated demonstrable impact on patient health and communication efficacy with high-tech and no-tech visual interface-based interventions and systematic nurse training interventions. Treatment effects primarily pertained to dependent variables of patient anxiety, communication satisfaction, comfort, symptom self-reporting, and nursing practice changes.

CONCLUSIONS

There is a paucity of high-quality AAC intervention research for mechanically ventilated and tracheostomy patients in critical and acute care settings. Emergent evidence suggests that select visual interface and nurse training interventions can impact efficacy of patient-provider communication and patients' overall health.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26506102.

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.

Workshop on hastened death as "space for an appreciative discussion": A qualitative study

AIM

To evaluate the suitability of a drama-based workshop as a method for ethical deliberation.

BACKGROUND

Nurses worldwide are inadequately prepared to care for people who desire hastened death, which can lead to ethical and moral dilemmas. To address this problem, we developed a drama-based ethical deliberation workshop to assist nurses in these situations. Senghor and Racine's three moments of ethical deliberation and their quality criteria served as basis for evaluation.

DESIGN

Qualitative descriptive study design.

METHODS

Non-participant observations and a survey with incomplete sentences to be completed by nursing students were used. Data analysis followed Mayring's deductive content analysis approach.

RESULTS

All three moments of ethical deliberation according to Senghor and Racine were identified. Participants recognised hastened death as morally problematic, shared their experiences and gained a deeper understanding of the problem. They reported feeling better prepared for encounters with persons seeking assisted suicide. In terms of its quality, the drama-based workshop achieved good and partial ethical deliberation.

CONCLUSIONS

The workshop has demonstrated its suitability as a method for ethical deliberation. The workshop should be complemented by specific modules, such as communication skills and be tailored to other professional groups. A validated instrument is needed to ensure a more comprehensive assessment of the quality.

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.

Exploring the influence of the spiritual climate on psychological empowerment among nurses in China: a cross-sectional study

BACKGROUND

Psychological empowerment notably impacts nurses' work engagement and high-quality care. A spiritual climate is a work environment that respects individuals and encourages them to express personal views. Previous studies have shown that a spiritual climate enhances psychological empowerment, however, the relationship between them among the nursing population remains unclear. This study aimed to explore the effect of a spiritual climate on nurses' psychological empowerment and provide a scientific basis for improving psychological empowerment among nurses.

METHODS

A cross-sectional survey of 837 nurses from five hospitals in Sichuan Province, Southwest China, was conducted using a convenience sampling method; this survey included nurses' demographic characteristics, the Psychological Empowerment Scale (PES), and the Chinese version of the Spiritual Climate Scale (C-SCS). The data were analysed using one-way analysis of variance (ANOVA), correlation analysis, and multiple linear regression.

RESULTS

The sample of 837 nurses attained a psychological empowerment score of (45.49 ± 6.42) and a spiritual climate score of (75.25 ± 16.75). The one-way ANOVA revealed that psychological empowerment scores among nurses varied based on differences in age, department, years of work experience, professional title, level of work intensity, and children (yes/no). Pearson's correlation analyses revealed a significant positive correlation between the spiritual climate and nurses' psychological empowerment (r = 0.564, P < 0.001), and multiple linear regression analysis showed that working in the intensive care unit (ICU), work intensity, and the four items pertaining to spiritual climate influenced nurses' psychological empowerment, explaining 32.6% of the total variance in psychological empowerment.

CONCLUSION

The findings suggested that the spiritual climate perceived by nurses and psychological empowerment are moderately high. Working in the ICU, work intensity, and the four items pertaining to spiritual climate influence nurses' psychological empowerment. Nursing managers should pay attention to the daily work intensity of nurses, especially ICU nurses, organize work tasks reasonably, promote dynamic and balanced nurse human resource deployment based on patients' conditions and nurses' workloads, and implement scientific scheduling plans to establish a positive spiritual climate in the workplace. Additionally, group workshops and systematic training programs can effectively enhance psychological empowerment among nurses.

"I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post-Dobbs

Background The 2022 Supreme Court ruling in Dobbs v Jackson Women's Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress-a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.

Moral distress among physicians in Norway: a longitudinal study

OBJECTIVES

To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses.

DESIGN

Longitudinal survey.

SETTING

Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021.

PARTICIPANTS

1499 physicians in 2004 and 2316 physicians in 2021.

MAIN OUTCOME MEASURES

The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work.

RESULTS

Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements.

CONCLUSION

In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

Intent to stay, moral distress, and nurse practice environment among long-term care nurses: A cross-sectional questionnaire survey study

BACKGROUND

Many long-term care facilities in the United States face significant problems with nurse retention and turnover. These challenges are attributed, at least in part, to moral distress and a negative nurse practice environment.

OBJECTIVE

The purpose of the study was divided into two parts: first, to investigate the relationships among nurse practice environment, moral distress, and intent to stay; second, to explore the potential mediating effect of the nurse practice environment on the intent to stay among those with high levels of moral distress.

DESIGN

This study was a descriptive, cross-sectional survey using targeted sampling.

PARTICIPANTS

A total of 215 participants completed the surveys. Participants were nationally representative of long-term care nurses by age, years of experience, employment status, and type of health setting.

METHODS

This study was an online national survey of long-term care nurses' perceptions of their intent to stay, moral distress level (Moral Distress Questionnaire), and nurse practice environment (Direct Care Staff Survey). Structural equation modeling analysis explored intent to stay, moral distress, and the nurse practice environment among long-term care nurses.

RESULTS

The mean moral distress score was low, while the mean nurse practice environment and intent to stay scores were high. Moral distress had a significant, moderately negative association with the nurse practice environment (β = -0.41), while the nurse practice environment had a significant, moderately positive association with intent to stay (β = 0.46). The moral distress had a significant, moderately negative association with intent to stay (β = -0.20). The computed structural equation modeling suggested a partially mediated model (indirect effect = -0.19, p = 0.001).

CONCLUSION

Since the nurse practice environment partially mediates the relationship between moral distress and intent to stay, interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.

CLINICAL RELEVANCE

Our study demonstrated that the nurse practice environment mediates moral distress and intent to stay. Interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.

The Big Squeeze: Factors Contributing to Moral Distress Among Radiologist Clinician-Educators

Moral distress is a term used to describe the cognitive-emotional dissonance that is experienced when one is compelled to act contrary to one's moral requirements. This occurs as a result of systemic constraints that prevent an individual from taking actions that they perceive as morally right, resulting in a perceived violation of one's core values and duties. There has been a growing interest in the prevalence of moral distress in healthcare, particularly as a root cause of burnout. A recent national survey on moral distress in radiology found that 98% of respondents experienced at least some degree of moral distress with 18% of respondents having left a position due to moral distress. One of the scenarios associated with the highest degree of moral distress related to the conflict that arises when one feels unable to fulfill teaching responsibilities due to high clinical demands. Now more than ever, clinician-educators are asked to do more with less time, fewer resources, and in an increasingly demanding work environment that is often discordant with providing quality education to their learners. In this manuscript, we aim to discuss the factors contributing to moral distress in radiologist clinician-educators as a framework to better understand the implications of these drivers, and to offer our perspective on potential mitigating measures.

The barometer of moral distress in midwifery: A pilot study

BACKGROUND

Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery.

AIM

The aim of this study was to pilot the Barometer of Moral Distress in Midwifery.

METHODS

This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity.

FINDINGS

A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores.

DISCUSSION/CONCLUSION

This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

Insights into the Impact of Organizational Factors and Burnout on the Employees of a For-Profit Psychiatric Hospital during the Third Wave of the COVID-19 Pandemic

In this paper, we provide insights into the interplay among the organizational, job, and attitudinal factors and employees' intentions to resign during the third wave of the COVID-19 pandemic at a mental health hospital. We point out shortcomings in the relationship dynamics between executive administration and operational staff and propose a pathway to develop more effective leadership frameworks to increase job satisfaction. We integrate qualitative data from case information and open-ended questions posed to employees at a mental health hospital and quantitative data from a small-scale survey (n = 19). We highlight that the ability to achieve objectives, work autonomy, burnout, affective commitment, distributive and procedural justice, and job satisfaction are critical in determining individuals' intentions to resign. Individuals identified disconnectedness and moral distress as critical aspects, while highlighting empathy, compassion, satisfaction, and confidence as pivotal elements. Mental healthcare settings could benefit from enhancing the staff's ability to achieve objectives, work autonomy, affective commitment, and both distributive and procedural justice. Addressing burnout and implementing measures to increase job satisfaction are equally vital. Efficiently restructuring dynamics between various leadership levels and staff can significantly improve employee retention.

Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals

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.

Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

BACKGROUND

Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

METHOD

We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

RESULTS

We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

CONCLUSIONS

Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.