Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study

Sources of moral distress in nursing professionals: A scoping review

This article presents a scoping review aimed at mapping the main sources of moral distress among nursing professionals. The review was conducted according to the Arksey and O'Malley methodology, using the SPIDER framework to guide the systematic search in the BVS, PubMed, PsycArticles, Scielo, and Scopus databases. Initially, 2320 publications were identified. After the application of inclusion and exclusion criteria, 83 studies were selected for analysis in terms of their methodological characteristics, objectives, practice contexts, and various sources of moral distress identified. The analysis facilitated the grouping of these sources into specific situations, reflecting the challenges experienced by nurses under different practice settings. This review augments the knowledge of the causes of moral distress in nursing, highlighting the impact of this phenomenon on the physical and mental health of professionals, as well as on the quality of care provided.

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.

[Theoretical foundations of clinical ethics consultation in psychiatry]

BACKGROUND

Clinical ethics consultants support mental health professionals in identifying and analyzing moral problems in clinical practice.

OBJECTIVE

Presentation of key ethical concepts and normative theories that are relevant for clinical ethics consultation in mental healthcare.

MATERIAL AND METHODS

Conceptual and ethical analyses.

RESULTS

After distinguishing between morality, ethics and law, moral problems are differentiated from other types of problems encountered in clinical practice. Subsequently, key ethical concepts and the concept of moral distress are clarified. In relation to the normative framework a distinction is made between philosophical ethical theories and medical ethical theories, such as principlism and the ethics of care. Finally, justification tests for ethical decision-making in situations of danger to self or others based on the harm principle and soft paternalism are proposed.

CONCLUSION

Knowledge of key ethical concepts and normative theories is important for the identification and analysis of moral problems in mental healthcare and should be given greater weight in the training of clinical ethics consultants.

Institution-Wide Moral Distress Among Nurses

BACKGROUND

Moral distress is the inability to do the right thing due to imposed constraints.

OBJECTIVE

Explore the presence of moral distress among nurses.

METHODS

A quantitative, exploratory, cross-sectional study at a level 1 trauma center using the Measure of Moral Distress for Healthcare Professionals (MMD-HP).

RESULTS

Ninety-seven nurses completed the MMD-HP. The top 3 items contributing to moral distress included inadequate staffing, inadequate resources, and lack of administrative support. Nurses who considered leaving had more moral distress. Moral distress explained 28.5% of the variance associated with nurses' "intent to leave" and "primary unit" ( P < 0.001). Moral distress for nurses 40 to 49 years of age was higher compared with nurses 50 years or older.

CONCLUSIONS

Moral distress involved deficiencies in staffing, resources, and administrative support. Research should explore interventions to mitigate moral distress among nurses by promoting safe staffing levels, the provision of adequate resources, and increased administrative support.

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.

Adaptation and validation of moral distress thermometer in Chinese nurses

BACKGROUND

Moral distress seriously affects professional nurses, and a number of instruments have been developed to measure the level of moral distress. The moral distress thermometer (MDT) is one of the commonly used instruments that can rapidly measure real-time moral distress; however, it remains unclear whether it is still useful in the Chinese cultural context.

AIM

This study aimed to adapt and validate the MDT among Chinese registered nurses.

RESEARCH DESIGN

An online, cross-sectional, survey study of adapting and validating Chinese version of MDT.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 182 registered nurses effectively finished this survey. The correlation between MDT score and the score of the moral distress scale-revised version (MDS-R) was used for evaluating convergent validity, and MDT scores of registered nurses who working in different departments and who made different actions to the final question of the MDS-R were compared by using one-way ANOVA to evaluate construct validity.

ETHICAL CONSIDERATIONS

The Ethics Committee of Chongqing Traditional Chinese Medicine Hospital approved this study.

RESULTS

The Chinese version of MDT was described as relevant to measure moral distress, with a reported item-level content validity index (I-CVI) and scale-level CVI (S-CVI) of 1. The mean MDT score and mean MDS-R score were 2.54 and 38.66, respectively, and the correlation between these two scores was significantly moderate (r = 0.41). Nurses working different departments reported different levels of moral distress, and those working in intensive care unit reported the highest level of moral distress than those working in other departments (p = 0.04). The MDT scores between nurses who presented different actions to their position were also significantly different, and those who had ever left and those who had considered leaving but did not leave reported significantly higher moral distress.

CONCLUSION

The MDT is a reliable, valid, and easy-to-use instrument to rapidly measure the real-time moral distress of registered nurses in China.

Moral distress thermometer: Swedish translation, cultural adaptation and validation

BACKGROUND

Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time.

AIM

The aim of this study was to translate the MDT and adapt it to the Swedish cultural context.

RESEARCH DESIGN

The first part of this study concerns the translation of MDT to the Swedish context, and the second part the psychometric testing of the Swedish version.

PARTICIPANTS AND RESEARCH CONTEXT

89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch's ANOVA, Games-Howell post-hoc test and Pearson's correlation analysis were done.

ETHICAL CONSIDERATIONS

The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration.

RESULTS

The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress.

CONCLUSION

The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context.

Care call requests and inpatient beds modernization: Is there any link? A prospective observational study in the oncological setting

AIM

The study aims to analyse the principal causes of patients' care calls and compare differences before and after inpatient beds' technological modernization in a surgical breast oncological ward.

DESIGN

A prospective observational study was conducted under the STROBE guidelines. Data were collected from June to September 2022.

METHODS

Statistical analyses were performed to compare each reason for care calls, by shifts and pre and post-inpatient bed modernization.

RESULTS

Two thousand five hundred and fifty-nine care request calls were analysed during the 202 observed shifts. The most frequent reason was related to the requests for positions.

CONCLUSION

Technological modernization of the beds has not led to effective-positive-changes; on the contrary, it seems at first glance to show an upward trend in calls above all in the short period after the changes.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

What problem did the study address? By analysing the principal causes of care calls and comparing the differences before and after inpatient beds' technological modernization, this study evaluates if inpatient gear or device modernization can impact care call requests. What were the main findings? The results show that the most frequent reasons for care calls were position, possession and other. These findings seem not superimposable; the hypothesis supported by the international literature in which the causes relating to potty and pain were found among the main reasons. Where and on whom will the research have an impact? These results could impact the care organizational area in nursing care and could improve care quality, patient satisfaction and safety.

REPORTING METHOD

This prospective observational study was conducted following STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

After adequate information (presentation, design methods and objectives), all unit healthcare staff agreed to collaborate in the study.

Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study

Background

Nurses in adult care settings frequently encounter moral distress due to the daily ethical obligations they must fulfill. In contrast to other healthcare professionals, nurses often grapple with a heightened frequency of moral dilemmas, resulting in increased moral distress.

Objective

This study aimed to explore the levels and relationship between moral caring competency and moral distress among Ghanaian nurses in adult care settings.

Methods

This quantitative study utilized a descriptive-correlational design. A multistage sampling was used to select three public hospitals. Simple random sampling was used to recruit 231 nurses from the three public hospitals. Data were collected from June to July 2023 using validated questionnaires. The study utilized frequency and percentages, mean and standard deviation, and Spearman's Correlation.

Results

The nurses had a low level of moral caring competency (M = 2.18, SD = 0.340). The composite moral distress score was 227.31, indicating a high level of moral distress among the nurses. Furthermore, there was a moderate, negative significant relationship between moral caring competency and moral distress (rs = -.474, N = 231, p <0.001).

Conclusions

Nurses in public hospitals had limited personal cognitive, affective, and psychomotor abilities to address patient moral issues. The nurses also experience significant moral distress when delivering patient care. Furthermore, to decrease the level of moral distress, moral caring competency should be strengthened among nurses. Therefore, it is recommended that nurse administrators provide adequate organizational support and implement continuous moral training to improve nurses' moral caring competency and mitigate their moral distress. Healthcare policymakers are encouraged to develop or refine policies to navigate moral dilemmas and reduce moral distress among nurses. Future studies employing qualitative designs can explore the influence of culture on moral caring competency within the Ghanaian setting.

Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.

Impact of Case Review Debriefings on Moral Distress of Extracorporeal Membrane Oxygenation Nurses

BACKGROUND

Moral distress occurs when nurses know the ethically correct action to take but are restrained from taking it. Moral distress is prevalent in nurses who work in intense stress situations, as do extracorporeal membrane oxygenation nurses.

LOCAL PROBLEM

Nurses who work in critical care settings have higher levels of moral distress than nurses who work in other practice areas. The purpose of this project was to evaluate the effectiveness of case review debriefings on moral distress of extracorporeal membrane oxygenation nurses.

METHODS

Thirty-nine critical care registered nurses with specialty training in extracorporeal membrane oxygenation were invited to participate in this clinical improvement project. The intervention consisted of 2 case review debriefings. The Moral Distress Scale-Revised and the Moral Distress Thermometer were used to measure long-term and acute (short-term) moral distress.

RESULTS

Of a potential range of 0 to 336, the mean Moral Distress Scale-Revised score was 134.0 before intervention and 131.8 after intervention. The frequency of experiencing moral distress did not change after intervention, but the level of moral distress increased after intervention. Moral Distress Thermometer scores decreased for 80% of participants and increased for 20%. Five items related to perceptions of prolonging death and suffering were the most frequent causes of moral distress.

CONCLUSIONS

Developing strategies and providing opportunities to mitigate moral distress are crucial to a healthy future nursing workforce. Implications include the potential for improved patient care, decreased turnover rates and costs, and improved nurse satisfaction rates.

How Do Nursing Students Perceive Moral Distress? An Interpretative Phenomenological Study

Background: Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress. The same applies to nursing students. This study aims to analyze episodes of moral distress experienced by nursing students during end-of-life care of onco-hematologic patients in hospital settings. Methods: This study was conducted in the interpretative paradigm using a hermeneutic phenomenological approach and data were analyzed following the principles of the Interpretative Phenomenological Analysis. Results: Seventeen participants were included in the study. The research team identified eight themes: causes of moral distress; factors that worsen or influence the experience of moral distress; feelings and emotions in morally distressing events; morally distressing events and consultation; strategies to cope with moral distress; recovering from morally distressing events; end-of-life accompaniment; internship clinical training, and nursing curriculum. Conclusions: Moral distress is often related to poor communication or lack of communication between health care professionals and patients or relatives and to the inability to satisfy patients’ last needs and wants. Further studies are necessary to examine the quantitative dimension of moral distress in nursing students. Students frequently experience moral distress in the onco-hematological setting.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review

BACKGROUND

No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley's instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale-Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress.

METHODS

A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological Abstracts Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle-Ottawa Scale.

RESULTS

Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review's findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores.

CONCLUSIONS

This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy

Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.