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.

Moral distress and moral sensitivity in clinical nurses

Health care providers are expected to have a certain moral sensitivity (MS) to make an ethical assessment. Moral distress (MD) is a common phenomenon in nursing. It can negatively affect nurses physically, psychologically, socially, and spiritually. This study aimed to investigate the relationship between MD and MS among nurses using a cross-sectional descriptive design. The study was conducted in two stages. The first stage was a methodological study that analyzed validity and reliability of the Measure of MD-Healthcare Professionals. The second stage was a descriptive- predictive analysis that investigated the relationship between MD and MS. The MD intensity and frequency scores of the participants were high and moderately high, respectively. There was no direct effect on the total score and frequency of MS and MD. However, a direct and significant negative effect of MS was seen on the intensity of MD. Based on the results of this study, MS should be considered as a measure in studies aimed at understanding MD among clinical nurses. Empowerment programs should be established to increase the awareness of health workers about ethical and moral situations and to support them to cope with the problems they experience in these areas.

Healthcare Providers' Experiences of Caring for Patients With COVID-19 Requiring Extracorporeal Membrane Oxygenation Support

BACKGROUND

Coronavirus 19 (COVID-19) affected healthcare workers (HCW) in ways more than increasing the volume of patients needing care. Increased numbers of patients at younger ages required support with extracorporeal membrane oxygenation (ECMO). Providing this care requires an interdisciplinary team.

AIM

This study explored the experiences of HCW caring for patients with COVID-19 on ECMO.

METHODS

Face-to-face semi-structured interviews were conducted via videoconferencing, and transcript comparison was used for the analysis.

FINDINGS

Open coding of the data generated 7 categories including (1) fearing the unknown, (2) confronting challenges in patient and/or family interactions, (3) encountering barriers to providing care, (4) facing moral distress, (5) working through exhaustion, (6) persevering by strengthening teamwork, (7) and acknowledging frustration with non-believers.

DISCUSSION

HCW balanced pessimism and optimism while caring for patient with COVID-19 on ECMO. They used negative experiences caring for these patients to strength teamwork and bonding among peers.

CONCLUSION

The practice implications for caring for patients with COVID-19 on ECMO include viligance by clinician and organization to protect the wellbeing of healthcare providers, particularly in ICU and ECMO units were moral distress and burnout can be high.

Nurses' experiences of moral distress and how it affects daily work in surgical care-a qualitative study

AIM

To describe nurses' and specialist nurses' experiences of moral distress and how it affects daily work in surgical care.

DESIGN

A qualitative descriptive study design was used.

METHODS

A qualitative study with 12 interviews with nurses and specialist nurses working in surgical care. All interviews were conducted during October and November 2022 in two hospitals in southeastern Sweden. Data were analysed using conventional qualitative content analysis.

FINDINGS

Three categories and seven subcategories generated from the data analysis. The three categories generated from the analysis were Experiences that lead to moral distress, Perceived consequences of moral distress and Strategies in case of moral distress. The results show that a lack of personnel in combination with people with complex surgical needs is the main source of moral distress. Both high demands on nurses as individuals and the teamwork are factors that generate moral distress and can have severe consequences for the safety of patients, individual nurses and future care.

CONCLUSIONS

The results show that moral distress is a problem for today's nurses and specialist nurses in surgical care. Action is necessary to prevent nurses from leaving surgical care. Prioritizing tasks is perceived as challenging for the profession, and moral distress can pose a patient safety risk.

IMPACT

Surgical care departments should design support structures for nurses, give nurses an authentic voice to express ethical concerns and allow them to practice surgical nursing in a way that does not violate their core professional values. Healthcare organizations should take this seriously and work strategically to make the nursing profession more attractive.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey

INTRODUCTION

By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support.

METHODS

A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making.

RESULTS

305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility.

CONCLUSION

Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Predictors of negative moral appraisals and their association with symptoms of post-traumatic stress and depression in the context of COVID-19 related stressors

Research on moral injury (MI) suggests that negative moral appraisals of stressful events can impact mental health in high-stakes occupational contexts (e.g., military). Few studies have examined these associations in the general population, limiting the generalisability of findings. Furthermore, factors that may predispose an individual to adverse outcomes in the context of moral stressors remain largely unknown. The objectives of this study were to (1) explore the applicability of the MI construct to stressors experienced by the general public during the COVID-19 pandemic; (2) explore how trait differences in sense of duty, religiosity/spirituality, anxiety sensitivity, and guilt, shame, and anger, predict negative moral appraisals of COVID-19 stressors. Participants (n = 355) completed an online survey assessing exposure to and appraisals of COVID-19 stressors, mental health symptoms, and dispositional characteristics (i.e., trait emotions, anxiety sensitivity, sense of duty, religiosity/spirituality). Path analysis revealed specific indirect associations between self-based moral appraisals and posttraumatic stress disorder (PTSD) and depression through guilt, and between both self- and other-based moral appraisals and PTSD and depression through anger. Number of COVID-19 stressors had no influence on associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Findings partially support the applicability of the MI construct outside the occupational context.

Gendered and racial experiences of moral distress: A scoping review

AIM

To inform efforts to integrate gender and race into moral distress research, the review investigates if and how gender and racial analyses have been incorporated in such research.

DESIGN

Scoping review.

METHODS

The PRISMA (Preferred Reporting Items for Systematic and Meta-Analysis) Extension for Scoping Reviews was adopted.

DATA SOURCES

Systematic literature search was conducted through PubMed, CINAHL and Web of Science databases. Boolean operators were used to identify moral distress literature which included gender and/or race data and published between 2012 and 2022.

RESULTS

After screening and full-text review, 73 articles reporting on original moral distress research were included. Analysis was conducted on how gender and race were incorporated in research and interpretation of moral distress experiences among healthcare professionals.

IMPACT

This study found that while there is an upward trend in including gender and race-disaggregated data in moral distress research, over half of such research did not conduct in-depth analysis of such data. Others only highlighted differential experiences such as moral distress levels of women vis-à-vis men. Only about 20% of publications interrogated how experiences of moral distress differed and/or explored factors behind their findings.

CONCLUSION

There is a need to not only collect disaggregated data in moral distress research but also engage this data through gender and race-based analysis. Particularly, we highlight the need for intersectional analysis, which can elucidate how social identities and categories (such as gender and race) and structural inequalities (such as those sustained by sexism and racism) interact to influence moral experiences.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Moral distress as experienced by healthcare professionals is increasingly recognized as an important area of research with significant policy implications in the healthcare sector. This study offers insights for nuanced and targeted policy approaches.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Organizational response to the COVID-19 pandemic and its association with moral distress in community mental health teams in the UK: A qualitative study

In March 2020, Coronavirus-19 (COVID-19) rapidly spread across the globe impacting the mental health of the population and putting an overwhelming pressure on health services. Much has been written about the impact of the pandemic on health-care workers working in hospital settings but less attention has been paid to its effect on community mental health teams (CMHTs). This study is based on 21 remote interviews with community mental health professionals during the first wave of the COVID-19 pandemic. Interviews were transcribed and analysed using a thematic analysis whereby codes of similar meaning were grouped into main themes. Analysis identified three major contributors to moral distress; changes in the nature of contact with service users, changes to the place of work, and difficulties of balancing risks to the families of CMHT staff and service users. This study demonstrates that necessary organizational changes instituted to minimize the spread of COVID-19, required different ways of working which were not perceived to be in the best interests of service users or the families of CMHT staff. In order to comply with Government directives, CMHT staff were forced to behave in a way which did not match their moral values causing them to experience moral distress.

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.

Moral distress among acute mental health nurses: A systematic review

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

Psychometric Evaluation of the Moral Comfort Questionnaire

Background and Purpose: The ethical challenges of the COVID-19 pandemic have contributed to an increase in moral distress (MD) in nurses-a long-standing, ubiquitous issue in nursing-highlighting its detrimental impact on nurses, patients, and healthcare organizations. MD is the negative outcome of a moral situation or dilemma in which a nurse is prevented from taking action on ethical decisions usually related to organizational constraints. On the opposite end of the spectrum, moral comfort (MC), an emerging concept in nursing, is an individual's feelings of ease with decisions and actions related to a moral dilemma or the positive outcome of a moral situation or dilemma. However, nursing literature on MC is sparse. While several instruments to measure MD exist, an instrument to measure MC was not found. The MC Questionnaire (MCQ) was theoretically developed. The purpose of this study was to conduct a psychometric evaluation of the new 35-item MCQ. Methods: Psychometric evaluation design was used. Reliability testing consisted of the examination of internal consistency (coefficient alpha values) and stability (test-retest reliability: Spearman's correlation coefficient, weighted Kappa, and Bland-Altman [B&A] analysis). Validity was examined using content validity (content expert evaluation) and discriminant validity (r < .30). Model fit of a proposed five-factor model was tested using confirmatory factor analysis (CFA). Results: Hospital-based direct-care (HB-DC) registered nurses (RNs; n = 466) participated from February 2019 to September 2019 in this Institutional Review Board-approved study. Participants completed demographic information, the MCQ, and the Moral Distress Scale-Revised (MDSR). The psychometric evaluation included a priori content validation and multiple statistical analyses: coefficient alpha, Spearman's correlation coefficient, weighted Kappa, B&A, discriminant validity, and CFA. Coefficient alpha was .951, suggesting internal consistency. Spearman's correlation coefficient was .605 (p < .001), suggesting a strong correlation between Time 1 and Time 2. Weighted Kappa values for each item (range = .139-.559) suggested slight to moderate agreement between responses over time. The B&A plot suggested agreement of responses over time. Discriminant validity results suggested no correlation between the MCQ and MDSR (r = -.219), which was expected. CFA results suggest a poor model fit of the proposed five-factor model. A post hoc hierarchical cluster analysis showed the presence of two clusters. A subsequent two-factor exploratory factor analysis showed items loading onto one of the two factors (internal and external). Conclusions: MC in nurses is essential to promoting positive outcomes for nurses. An instrument to measure MC in nurses is needed to gain a further understanding of the concept. The MCQ was theoretically developed and psychometrically evaluated. Results suggest the validity and reliability of the MCQ with further testing of a two-factor model. Knowledge acquired from studies using the MCQ could potentially be used to develop strategies to promote MC in nurses, thereby promoting positive outcomes for nurses, patients, and healthcare organizations.

Reliability of Moral Distress Scale, Secondary Traumatic Stress Scale, and Jefferson Scale of Empathy Among Greek Nurses: A Pilot Study

Background and Purpose: Moral distress (MD), secondary traumatic stress (STS), and empathy are of particular interest to the nursing profession. The availability of validated tools for the assessment of these parameters is of high importance. The primary aim of this pilot study was to evaluate the reliability of the Greek version of the MD Scale or the revised version (MDS-R), the Jefferson Scale of Empathy for Health Professionals (JSE-HP), and the STS Scale (STSS) in Greek nurses working in open and psychiatric wards. Methods: To assess the reliability of scales, internal consistency (coefficient alphas) and test-retest (interclass correlation coefficients [ICCs]) were calculated. Results: A total of 38 nurses took part in the study. All scales and subscales presented excellent stability (.876 ≤ ICC ≤ .963, p < .0001) and acceptable to excellent internal consistency reliability (first measurement, .796 ≤ coefficient alpha ≤ .959; second measurement, .794 ≤ coefficient alpha ≤ .956). Conclusions: The Greek version of MDS-R, STSS, and JSE-HP may be proposed for the assessment of relevant variables in Greek nursing staff.

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.

The impact of transition programs on well-being, experiences of work environment and turnover intentionamong early career hospital nurses

BACKGROUND

Transition programs for newly graduated nurses in hospital settings are reported to provide learning opportunities, strengthening confidence, workplace integration and skills, retention and job satisfaction. Still, our knowledge of long-term effects is scarce and few studies have used control groups.

OBJECTIVE

To explore the long-term impact of having attended a transition program on the nurses' experiences of the first years of practice. More specifically, ideology-infused psychological contract, ethical stress, perceived organizational support, job satisfaction, opportunities for learning, and intention to stay in the nursing profession, were explored as outcome variables.

METHODS

A questionnaire survey was carried out among registered nurses from November 2019 to January 2020, with a 54% response rate. The analysis was based on 149 nurses who had attended a transition program, and 72 who had not attended. The nurses had seniority between one and three years. Independent samples t-test were used to investigate differences between the groups.

RESULTS

The two groups showed small and non-significant differences in the outcome variables. However, regarding the frequency of ethical value conflicts induced by insufficient resources, as well as experiences of ethical value conflict distress, the group of nurses who had attended a transition program showed statistically significantly higher mean values, although the effect sizes were small.

CONCLUSION

Newly graduated nurses need more than transition programs and skills training to progress in their nursing role and develop competence, increase job satisfaction, and reduce stress. Achieving these goals requires a long-term supportive learning environment that is integrated into everyday work.

Determining the Impact of Hurricane Dorian and the Covid-19 Pandemic on Moral Distress in Emergency Medical Providers at the Rand Memorial Hospital: Moral distress in emergency medical personnel

OBJECTIVES

The aim of this work was to determine the impact of Moral Distress (MD) in emergency physicians, nurses, and emergency medical service staff at the Rand Memorial Hospital (RMH) in the Bahamas, and the impact of Hurricane Dorian and the COVID-19 pandemic on Moral Distress.

METHOD

A cross-sectional study utilizing a 3-part survey, which collected sociodemographic information, Hurricane Dorian and COVID-19 experiences, as well as responses to a validated modified Moral Distress Scale (MDS).

RESULTS

Participants with 2 negatively impactful experiences from COVID-19 had statistically significantly increased MD compared to participants with only 1 negatively impactful experience (40.4 vs. 23.6, P = 0.014). Losing a loved one due to COVID-19 was associated with significantly decreased MD (B = - 0.42, 95% CI -19.70 to -0.88, P = 0.03). Losing a loved one due to Hurricane Dorian had a non-statistically significant trend towards higher MD scores (B = 0.34, 95% CI -1.23 to 28.75, P = 0.07).

CONCLUSION

The emergency medical staff at the RMH reported having mild - moderate MD. This is one of the first studies to look at the impact of concurrent disasters on MD in emergency medical providers in the Bahamas.

Nursing students' experience of moral distress in clinical settings: A phenomenological study

AIM

To explore nursing students' moral distress (MD) experiences in clinical settings.

DESIGN

An interpretative phenomenological analysis (IPA) design was employed.

METHODS

Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method.

RESULTS

Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity.

CONCLUSION

Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Reliability and validity of the revised Rushton Moral Resilience Scale for healthcare workers

AIM

To refine the Rushton Moral Resilience Scale (RMRS) by creating a more concise scale, improving the reliability, particularly of the personal integrity subscale and providing further evidence of validity.

BACKGROUND

Healthcare workers are exposed to moral adversity in practice. When unable to preserve/restore their integrity, moral suffering ensues. Moral resilience is a resource that may mitigate negative consequences. To better understand mechanisms for doing so, a valid and reliable measurement tool is necessary.

DESIGN

Cross-sectional survey.

METHODS

Participants (N = 1297) had completed ≥1 items on the RMRS as part of the baseline survey of a larger longitudinal study. Item analysis, confirmatory factor analyses, reliability analyses (Cronbach's alpha), and correlations were used to establish reliability and validity of the revised RMRS.

RESULTS

Item and confirmatory factor analysis were used to refine the RMRS from 21 to 16 items. The four-factor structure (responses to moral adversity, personal integrity, relational integrity and moral efficacy) demonstrated adequate fit in follow-up confirmatory analyses in the initial and hold-out sub-samples. All subscales and the total scale had adequate reliabilities (α ≥ 0.70). A higher-order factor analysis supports the computation of either subscale scores or a total scale score. Correlations of scores with stress, anxiety, depression and moral distress provide evidence of the scale's validity. Reliability of the personal integrity subscale improved.

CONCLUSION AND IMPLICATIONS

The RMRS-16 demonstrates adequate reliability and validity, particularly the personal integrity subscale. Moral resilience is an important lever for reducing consequences when confronted with ethical challenges in practice. Improved reliability of the four subscales and having a shorter overall scale allow for targeted application and will facilitate further research and intervention development.

PATIENT/PUBLIC CONTRIBUTION

Data came from a larger study of Canadian healthcare workers from multiple healthcare organizations who completed a survey about their experiences during COVID-19.

Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

Exploring the role of personality, perfectionism, and self-compassion on the relationship between clinical decision-making and nurses' wellbeing

BACKGROUND

Clinical decision-making is a core competency of the nursing role, with nurses having to make decisions surrounding patient care and patient safety daily. With decision-making being linked to psychological outcomes, it is important to consider potential areas that may support or hinder nurses' wellbeing whilst navigating clinical decisions.

AIM

The present study sought to investigate the relationship between clinical decision-making and moral distress, and further explore the role of personality, perfectionism, philotimo (a virtue describing the desire to do right by oneself and others, aligning with one's sense of morality), and self-compassion.

DESIGN

An online cross-sectional survey was conducted using Qualtrics. Associations between clinical decision-making and moral distress, burnout, personality, perfectionism, philotimo, and self-compassion were examined using univariate and multivariate statistics.

METHODS

One hundred and forty-three nurses from the United Kingdom completed an online questionnaire. Eligibility criteria included individuals who had practised in the nursing profession for a minimum of six months. To ensure that all participants were practising across the United Kingdom, the eligibility criteria was made clear in the study advertisement, and the consent form. The consent form required participants to confirm that they reached these criteria to proceed with the study.

RESULTS

Results revealed that clinical decision-making was associated with moral distress experience, and that both openness to experience, and philotimo mediated this relationship, independently. In addition to this, self-compassion was significantly associated with clinical decision-making across senior banded nursing roles, but this was non-significant for junior banded nursing roles.

CONCLUSION

Findings highlight the role of individual differences when looking at the impact of clinical decision-making upon nurses' wellbeing and offers explanation for any variance in moral distress experience across nursing professionals. This research identifies fundamental differences between junior and senior nurses in relation to clinical decision-making and self-compassion that should be considered in future research.

Critical care nurse leaders addressing moral distress: A qualitative study

BACKGROUND

Moral distress (MD) occurs when clinicians are constrained from taking what they believe to be ethically appropriate actions. When unattended, MD may result in moral injury and/or suffering. Literature surrounding how unit-based critical care nurse leaders address MD in practice is limited.

AIM

The aim of this study was to explore how ICU nurse leaders recognize and address MD among their staff.

STUDY DESIGN

Qualitative descriptive with inductive thematic analysis.

RESULTS

Five ICU nurse leaders participated in a one-time individual interview. Interview results suggest that (1) ICU nurse leaders can recognize and address MD among their staff and (2) nurse leaders experience MD themselves, which may be exacerbated by their leadership role and responsibilities.

CONCLUSIONS

Further research is needed to develop interventions aimed at addressing MD among nurse leaders and equipping nurse leaders with the skills to identify and address MD within their staff and themselves.

RELEVANCE TO CLINICAL PRACTICE

MD is an unavoidable phenomenon ICU nurse leaders are challenged with addressing in their day-to-day practice. As leaders, recognizing and addressing MD is a necessary task relating to mitigating burnout and turnover and addressing well-being among staff within the ICU.

Enhancing the moral courage of nurses: A modified Delphi study

BACKGROUND

The urgency of ensuring adequate moral courage in clinical nursing practice is evident. However, currently, there are few formal intervention plans targeted at enhancing the moral courage of nurses.

AIM

To develop a training program for improving the moral courage of nurses using the modified Delphi method.

RESEARCH DESIGN

A modified Delphi study.

PARTICIPANTS AND RESEARCH CONTEXT

From November to December 2022, a literature review and expert group discussion were conducted to develop a preliminary training plan framework. From January to March 2023, a two-round Delphi survey was performed, and a consensus was reached regarding the plan through online questionnaires. Descriptive statistics were used to analyze the data.

ETHICAL CONSIDERATIONS

This study was approved by the institutional ethics committee (No. 138, 30 August 2021). All participants provided written informed consent.

RESULTS

Consensus was reached on eight themes and 33 items to strengthen the moral courage training program for nurses.

CONCLUSIONS

Guided by a unified goal of moral education, a multi-level and acceptable intervention plan was designed to enhance the moral courage of nurses.

Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

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.

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

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.

Stretching oneself too thin and facing ethical challenges: Healthcare professionals' experiences during the COVID-19 pandemic

BACKGROUNDS

Most countries are facing increased pressure on healthcare resources. A better understanding of how healthcare providers respond to new demands is relevant for future pandemics and other crises.

OBJECTIVES

This study aimed to explore what nurses and doctors in Norway reported as their main ethical challenges during two periods of the COVID-19 pandemic: February 2021 and February 2022.

RESEARCH DESIGN

A longitudinal repeated cross-sectional study was conducted in the Western health region of Norway. The survey included an open-ended question about ethical challenges among doctors and nurses in hospital departments. Free-text comments were analysed using Systematic Text Condensation and also presented in a frequency table.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the Regional Research Ethics Committee in Western Norway (131,421). All participants provided consent when participating in the study.

RESULTS

In 2021, 249 and in 2022, 163 healthcare professionals responded to the open-ended question. Nurses and doctors reported three main categories of ethical challenges related to the COVID-19 pandemic: (1) barriers that hindered them in acting as they ethically would have wanted to do; (2) priority-setting dilemmas linked to overtreatment, transfer of resources and ranking patient needs; and (3) workload expansion threatening work-life balance and employees' health. Category one comprised of resource barriers, regulatory barriers, system barriers, and personal barriers. Regulatory barriers, especially visitor restrictions for next-of-kin, were the most frequently reported in 2021. Resource barriers, related to the increased scarcity of qualified staff, were most frequently reported in 2022. Clinicians stretched themselves thin to avoid compromising on care, diagnostics, or treatment.

CONCLUSIONS

Developing clinicians' ability to handle and cope with limited healthcare resources is necessary. To foster resilience and sustainability, healthcare leaders, in collaboration with their staff, should ensure fair priority-setting and initiate reflections among doctors and nurses on what it implies to provide 'good enough' care.

Development and Implementation of a Stress Monitoring Paradigm Using Virtual Reality Simulation During the COVID-19 Pandemic

Healthcare providers, particularly during the COVID-19 crisis, have been forced to make difficult decisions and have reported acting in ways that are contrary to their moral values, integrity, and professional commitments, given the constraints in their work environments. Those actions and decisions may lead to healthcare providers' moral suffering and distress. This work outlines the development of the Moral Distress Virtual Reality Simulator (Moral Distress VRS) to research stress and moral distress among healthcare workers during the COVID-19 pandemic. The Moral Distress VRS was developed based on the agile methodology framework, with three simultaneous development streams. It followed a two-week sprint cycle, ending with meetings with stakeholders and subject matter experts, whereby the project requirements, scope, and features were revised, and feedback was provided on the prototypes until reaching the final prototype that was deployed for in-person study sessions. The final prototype had two user interfaces (UIs), one for the participant and one for the researcher, with voice narration and customizable character models wearing medical personal protective equipment, and followed a tree-based dialogue scenario, outputting a video recording of the session. The virtual environment replicated an ICU nursing station and a fully equipped patient room. We present the development process that guided this project, how different teams worked together and in parallel, and detail the decisions and outcomes in creating each major component within a limited deadline. Finally, we list the most significant challenges and difficulties faced and recommendations on how to solve them.

Moral failure, moral prudence, and character challenges in residential care during the Covid-19 pandemic

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents' health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre's sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents' interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students' early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively.

Explaining the Impact of the COVID-19 Pandemic on Massage Therapists in Australia and Canada: A Mixed Methods Study

Background: The COVID-19 pandemic was a time of rapid change and uncertainty, with individual jurisdictions within countries implementing a variety of preventative measures. At the onset of the pandemic, as little was known about how COVID-19 was transmitted, restrictions, such as lockdowns, were implemented to prevent further spread of this virus. In many jurisdictions, massage therapists were deemed as nonessential for a period. This disruption to their livelihood, as a professional group and without autonomy to decide, was unprecedented. This prompted the question as to whether this experience had impacted massage therapists' professional identity. Methods: A sequential explanatory mixed methods design was used and massage therapists in Australia and Canada were recruited to participate. Results from a quantitative questionnaire completed by 649 respondents and from 31 semistructured interviews from a subset of the questionnaire participants were used in the mixed analysis. Results: Massage therapists, impacted by the pandemic, experienced a discord between what it means to be a massage therapist, providing patient-centered care and the public health initiatives implemented during the pandemic. This discord occurred in multiple situations and the type of discord was influenced by a number of factors, including how therapists identified themselves within the workforce (i.e., as a health care provider or a service provider). Conclusion: This study sought to understand how the COVID-19 pandemic impacted massage therapists' professional identity. Massage therapists reported that the pandemic impacted their professional identity through a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist. The sequela to this discord was therapists experiencing different types of moral distress and or moral injury. Future research is needed to determine the longer-term impacts of COVID-19 on massage therapists.

The role of perceived organizational support for nurses' ability to handle and resolve ethical value conflicts: A mixed methods study

AIM

To explore if and how nurses' perceived organizational support affects their ability to handle and resolve ethical value conflicts.

DESIGN

A mixed methods design with a longitudinal questionnaire survey and focus group interviews.

METHODS

A questionnaire survey in six hospitals in two Swedish regions provided data from 711 nurses responding twice (November-January 2019/2020 and November-January 2020/2021). A cross-lagged path model tested the mutual prospective influence between the organizational climate of perceived organizational support, frequency of ethical value conflicts, and resulting moral distress. Four focus group interviews were conducted with 21 strategically selected nurses (April-October 2021). Qualitative data collection and analysis were inspired by Grounded Theory.

RESULTS

A climate of perceived organizational support was empowering, contributing to role security. It prospectively decreased the frequency of ethical value conflicts but not the moral distress when conflicts did occur.

CONCLUSION

It is important to facilitate the development of perceived organizational support among nurses, but also to reduce the occurrence of ethical value conflicts that the nurses cannot resolve.

IMPLICATIONS FOR THE PROFESSION

By ensuring a shared care ideology, good inter-professional relations within the entire care organization, providing clear and supportive organizational structures, and utilizing competence adequately, healthcare managers can facilitate and support the development of perceived organizational support among nurses. Nurses who are empowered by perceived organizational support are stimulated by and take pride in their work and experience the work as meaningful and joyful.

IMPACT

The study addressed the question of whether healthcare organizations could support nurses to resolving ethical value conflicts, and thus reduce moral distress. Perceived organizational support is related to factors such as ideological caring alignment and supportive organizational preconditions. This study contributes specific knowledge about how healthcare organizations can empower nurses to effectively resolve ethical value conflicts and thereby reduce their moral distress.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Applicability and Validity of Second Victim Assessment Instruments among General Practitioners and Healthcare Assistants (SEVID-IX Study)

BACKGROUND

The second victim phenomenon and moral injury are acknowledged entities of psychological harm for healthcare providers. Both pose risks to patients, healthcare workers, and medical institutions, leading to further adverse events, economic burden, and dysfunctionality. Preceding studies in Germany and Austria showed a prevalence of second victim phenomena exceeding 53 percent among physicians, nurses, emergency physicians, and pediatricians. Using two German instruments for assessing moral injury and second victim phenomena, this study aimed to evaluate their feasibility for general practitioners and healthcare assistants.

METHODS

We conducted a nationwide anonymous online survey in Germany among general practitioners and healthcare assistants utilizing the SeViD (Second Victims in Deutschland) questionnaire, the German version of the Second Victim Experience and Support Tool Revised Version (G-SVESTR), and the German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP).

RESULTS

Out of 108 participants, 67 completed the survey. In G-SVESTR, the collegial support items exhibited lower internal consistency than in prior studies, while all other scales showed good-quality properties. Personality traits, especially neuroticism, negatively correlated to age, seem to play a significant role in symptom count and warrant further evaluation. Multiple linear regression indicated that neuroticism, agreeableness, G-SVESTR, and G-MISS-HP were significant predictors of symptom count. Furthermore, moral injury partially mediated the relationship between second victim experience and symptom count.

DISCUSSION

The results demonstrate the feasible use of the questionnaires, except for collegial support. With respect to selection bias and the cross-sectional design of the study, moral injury may be subsequent to the second victim phenomenon, strongly influencing symptom count in retrospect. This aspect should be thoroughly evaluated in future studies.

Moral Distress, Conscientious Practice, and the Endurance of Ethics in Health Care through Times of Crisis and Calm

When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout.

Digital Interventions for Stress Among Frontline Health Care Workers: Results From a Pilot Feasibility Cohort Trial

BACKGROUND

The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time.

OBJECTIVE

This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention.

METHODS

We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi-open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective.

RESULTS

All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app.

CONCLUSIONS

Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies.

TRIAL REGISTRATION

ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32240.

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation

OBJECTIVE

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence.

HYPOTHESIS

Moral distress will be significant in a dedicated pediatric trach/vent unit.

METHODS

The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed.

RESULTS

Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively).

CONCLUSIONS

Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

Compassionate Care: A Qualitative Exploration of Nurses' Inner Resources in the Face of Burnout

There is a universal shortage of nurses, with a current needs-based shortage of 5.9 million. This is not solely a recruitment issue but one of retention, triggered by high levels of work-induced stress, burnout, and reports of low job satisfaction resulting in poor care delivery. Some of the health repercussions on nurses include anxiety, insomnia, depression, migraines, irritability, absenteeism, and sometimes alcoholism and drug abuse. To tackle some of these costly issues, a qualitative exploration into how inner resources is used by nurses to cope with stress at different points of their careers is proposed. Through the lens of grounded theory, semi-structured interviews will be carried out with two distinct sets of participants: (1) Student nurses registered at the University of the Illes Baleares between 2022-2025. (2) Experienced nurses on the Balearic nursing register. Interviews will be coded and then analysed using Atlas.ti. Expected results will inform curriculum improvements that will benefit the well-being of (student) nurses, from the outset of their training, pre-empting potential psycho-social risks before they arise in the workplace. This is vital as it addresses nurses' mental health as well as chronic issues of retention and absenteeism.

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.

Moral courage and its influencing factor among oncology specialist nurses: A multi-centre cross-sectional study

AIM

Moral courage among healthcare workers has been extensively studied. However, few studies have been conducted on oncology specialist nurses, who frequently encounter complex moral situations. This study aimed to describe the current situation regarding moral courage and explored its influence on oncology specialist nurses in China.

DESIGN

This was an exploratory, descriptive study.

METHODS

A convenience sample of 390 nurses was conducted from 15 hospitals in Sichuan Province, China, between March and May 2023. Participants were assessed using the Moral Distress Scale-Revised, Nurses' Moral Courage Scale and the Moral Sensitivity Questionnaire.

RESULTS

The results demonstrated that moral courage was negatively associated with moral distress, and positively associated with moral sensitivity. Having a master's degree or above, an intermediate title or senior title, medical ethics training, moral distress or moral sensitivity contributed to explaining 54.1% of the variance in moral courage.

CONCLUSIONS

Moral courage was associated with several factors. Developing clinical intervention strategies and effective teaching methods will be critical for improving moral courage. No Patient or Public Contribution.

Family physicians' moral distress when caring for patients experiencing social inequities: a critical narrative inquiry in primary care

BACKGROUND

Family physicians (GPs) working with patients experiencing social inequities have witnessed patients' healthcare needs proliferate. Alongside increased workload demands fostered within current remuneration structures, this has generated concerning reports of family physician attrition and possible experiences of moral distress.

AIM

To explore stories of moral distress shared by family physicians caring for patients experiencing health needs related to social inequities.

DESIGN AND SETTING

A critical narrative inquiry, informed by the analytic lens of moral distress, conducted in Ontario, Canada.

METHOD

Twenty family physicians were recruited through purposive and snowball sampling via word of mouth and email mailing lists relevant to addictions and mental health care. Physicians participated in two narrative interviews and had the opportunity to review the interview transcripts.

RESULTS

Family physicians' accounts of moral distress were linked to policies governing physician remuneration, scope of practice, and the availability of social welfare programmes. These structural elements left physicians unable to get patients much needed support and resources.

CONCLUSION

This study provides evidence that physicians experience moral distress when unable to offer crucial resources to improve the health of patients with complex social needs resulting from structural features of the Canadian health and social welfare system. Further research is needed to critically interrogate how health and social welfare systems around the world can be reformed to improve the health of patients and increase family physicians' professional quality of life, potentially improving retention.

Nurse Reports of Moral Distress During the COVID-19 Pandemic

Background

COVID-19 was devastating for many frontline nurses embroiled in health care's response. Most media outlets reported from several large metropolitan areas in New York, California, and Florida, leaving other regions to wonder about the extent to which their nurses were suffering.

Objective

The purpose of this article was to understand the specific needs and experiences of Northeast Ohio nurses caring for patients with COVID-19 before designing interventions targeting negative mental outcomes.

Methods

This phenomenological study interviewed 16 Northeast Ohio nurses to understand their experiences of caring for patients with COVID-19.

Results

Although not asked about it directly, the participants' stories consistently included details that could be linked to moral distress. Two themes describing their lived experiences included "acquiring moral distress" and "living with moral distress." Additional findings are also reported separately because although they do not represent the lived experience of COVID-19 nursing, they did represent significant concerns that participants had for the future and are reported here to assist other researchers with the intervention design. Furthermore, these participants thought that participation in support groups with other nurses who cared for COVID-19 patients and possibly led by mental health advanced practice nurses offered the best intervention to process their trauma from the pandemic.

Conclusions

The long-term effects of moral distress have been discussed routinely in recent literature and are further complicated by the effects of the COVID-19 pandemic. Threats to the shrinking workforce of nurses must be taken seriously and interventions to improve the mental health and morale of frontline nurses must be prioritized and tested.

Re-examining the relationship between moral distress and moral agency in nursing

In recent years, the phenomenon of moral distress has been critically examined-and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re-examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re-centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of 'narrow' moral distress and the value of re-considering moral distress.  Finally, we provide an action-oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency.

Nurturing moral community: A novel moral distress peer support navigator tool

Moral distress is a pervasive phenomenon in healthcare for which there is no straightforward "solution." Rhetoric surrounding moral distress has shifted over time, with some scholars arguing that moral distress needs to be remedied, resolved, and eradicated, while others recognize that moral distress can have some positive value. The authors of this paper recognize that moral distress has value in its function as a warning sign, signaling the presence of an ethical issue related to patient care that requires deeper exploration, rather than evidencing identification of the "right" course of action. Once the experience of moral distress is identified, steps ought to be taken to clarify the moral issue, and, if possible and reasonable, the patient's values ought to be prioritized. This paper offers concrete actions steps, drawn from theory, which can be used in clinical practice to provide peer support or to facilitate self-reflection for morally distressed individuals. This approach empowers morally distressed individuals to explore ethical issues, identify concrete steps that can be taken, and mitigate feelings of powerlessness that are often associated with moral-constraint distress. The questions guide individuals and peers to reflect first on the micro-space and then more broadly on the institutional culture, facilitating meso- and macro-reflection and action.

Adaptation and Validation of a Moral Distress Instrument in Mental Health Nurses

Background and Purpose: To adapt and validate the Brazilian Scale of Moral Distress in Nurses for the mental health field. Methods: A cross-sectional methodological study was carried out, adapted with the contribution of 34 specialists, and validated by 173 mental health nurses. Results: The validated scale consists of 37 items divided into seven factors, and they were responsible for 77.2% of variance-working conditions, advocacy for the values and rights, professional safety and autonomy, ethical violations, social conflicts, ethical-professional competence, and conflicts with the management, with Cronbach's alpha at .972 for the entire instrument, and ranging from .852 to .949 for the constructs. Conclusion: The results provide evidence that the adapted instrument is reliable, valid, and consistent in measuring moral distress in mental health nurses.

Thriving at work, career calling, and moral distress among nurses

BACKGROUND

Emergency nurses who thrive at work experience positive emotions that help reduce burnout and thus enhance career calling. However, few studies have focused on the relationships among thriving at work, career calling, and moral distress among emergency nurses.

OBJECTIVES

To investigate the relationships among thriving at work, career calling, and moral distress and to explore the mediating role of career calling in the relationship between thriving at work and moral distress among emergency nurses.

DESIGN

A quantitative, cross-sectional study.

METHODS

A cross-sectional study was conducted by reference to 390 emergency nurses in China using an online survey that include the Thriving at Work Scale, the Career Calling Scale, and the Moral Distress Scale-Revised. The data were analyzed using SmartPLS software.

ETHICAL CONSIDERATION

The study was approved by the Ethics Committee of Hunan Normal University (No. 2023-388).

FINDINGS

Among emergency nurses, thriving at work is positively associated with career calling, while career calling is negatively associated with moral distress. Career calling negatively and completely mediates the relationship between thriving at work and moral distress (β = -0.087, p < 0.01).

DISCUSSION

Theoretically, the findings enhance our understanding of the relationships among thriving at work, career calling, and moral distress among emergency nurses.

CONCLUSION

By emphasizing the benefits of thriving at work, nursing managers can improve nurses' level of thriving at work by providing a favorable environment, a flexible scheduling system, and appropriate authorization as well as by ensuring organizational fairness and providing training opportunities in a hierarchical manner.

"You treat what you have to treat, and you don't care as much if they understand or if they feel good about it": Communication barriers and perceptions of moral distress among doctors in emergency departments

Doctors facing communication barriers when assessing patients in emergency departments (ED) is a frequent phenomenon, as the global prevalence of dementia and migration have increased. This study aims to explore how communication barriers influence moral distress as perceived by medical doctors working at emergency departments. Twelve doctors at 2 different EDs in Stockholm, Sweden, participated. Answers on communication barriers were collected from an interview guide on moral distress. Informants' responses were analyzed using qualitative thematic analysis. The results suggest that doctors experience moral distress when assessing patients with communication barriers due to an inability to mediate calm and safety and understand their patients, and due an increased need of resources and difficulties in obtaining consent before conducting examinations or interventions. In conclusion, communication barriers can be a cause of moral distress, which should be considered when developing tools and methods to mitigate and manage moral distress.

Out-of-hours decision-making in deteriorating patients by foundation year doctors: Relationship to moral distress

BACKGROUND

Moral distress (MD) refers to psychological unease when healthcare professionals identify morally correct actions to take but are constrained in their ability to take those actions.

METHODS

This study evaluated the relationship between out-of-hours decisions and MD among 40 Foundation Year 2 (FY2) doctors. They were asked to choose the 'expected' and the 'right' management options for five out-of-hours scenarios and complete an adapted Measure of Moral Distress for Health Professionals (MMD-HP) questionnaire.

RESULTS

28/40 (70%) reported discordance between 'expected' and 'right' options more frequently than concordance. The mean total MMD-HP score was low: 64.9 (SD = 26.9), range 13-143, maximum 288. The association between decision-making discordance and MMD-HP score was weak.

CONCLUSION

Out-of-hours decisions by FY2 doctors were characterised by doing what is 'expected' rather than what is perceived to be 'right'. Providing guidance regarding decision-making in deteriorating patients is needed for patient safety and staff well-being.

Moral distress experienced by care leaders' in older adult care: A qualitative study

BACKGROUND

Many healthcare professionals have left their professions recently because of increased moral distress, and the COVID-19 pandemic has had a further major impact on the ever-changing healthcare environment.

AIM

The purpose of the study was to examine care leaders' experiences of moral distress in their daily work in older adult care.

METHODOLOGY

A qualitative design was used. The data consisted of texts from interviews with care leaders (N = 8) in an older adult care context. Content analysis was used to analyse the data.

FINDINGS

Five themes emerged: (1) moral distress arises from a lack of time, (2) moral distress contributes to a sense of inadequacy but also a sense of responsibility, (3) moral distress arises from an imbalance in values, (4) increased knowledge and open discussion help reduce moral distress and (5) reflection, increased support and increased resources can reduce moral distress.

CONCLUSION

Moral distress is something that care leaders, according to this study, experience daily in an older adult care context and it is considered to have increased. Care leaders can experience moral distress from a lack of time; patient-related, relative-related or other ethically difficult situations or an imbalance between own values and an organisation's, other caregivers', patients' and/or patients' relatives values. Increased staffing resources, more knowledge (training and lectures) and time for reflection individually, in groups or with an outside expert could increase care leaders' insights into and ability to reduce moral distress. Although situations that are characterised by moral distress are burdensome, care leaders have the opportunity to learn from such situations through reflection and discussion and can develop strategies for future ethical challenges. Future research could focus on exploring caregivers' experiences of moral distress.

The impact of resilience on clinical nurses' moral courage during COVID-19: A moderated mediation model of ethical climate and moral distress

AIM

The purpose of this study was to explore whether clinical ethical climate mediates the relationship between resilience and moral courage in a population of clinical nurses during COVID-19, and if moral distress faced by nurses is a moderating factor.

BACKGROUND

Resilience can help nurses maintain their personal health during COVID-19 when they face great physical and psychological shock and are prone to health problems. Moral courage, as an ethical competency, helps nursing staff in adhering to the principles and values of professional ethics. There is a strong correlation between resilience and moral courage, but the mechanism by which resilience contributes to moral courage is unclear.

METHOD

A cross-sectional study research is designed. Three hundred thirty clinical nurses from six hospitals in Beijing, Sichuan, and Fujian of China were included between August 2021 and March 2022. The survey instruments include the Nurses' Moral Courage Scale (NMCS), Connor-Davidson Resilience Scale (CD-RISC), Moral Distress Scale-Revised (MDS-R), and Hospital Ethical Climate Scale (HECS).

RESULTS

Ethical climate mediates 15% of the relationship between resilience and moral courage. The association between resilience and ethical climate, as well as the indirect relationship between resilience and moral courage, was modified by moral distress.

DISCUSSION

This study investigated the mechanisms by which resilience affects moral courage in clinical nurses in the context of COVID-19, suggesting that moral courage can be increased by alleviating moral distress and increasing ethical climate.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study confirms the mediating effect of moral climate on the relationship between resilience and moral courage, as well as the moderating effect of moral distress. Hospital policymakers should value nurses' psychological resilience and moral courage, develop effective policies to prevent and manage stressors, build social support systems, and create a positive ethical climate.

"I couldn't": A phenomenological exploration of ethical tensions experienced by bereaved family members during the pandemic

INTRODUCTION

The COVID-19 pandemic entailed significant changes in accompaniment, end-of-life, and bereavement experiences. In some countries, public health measures prevented or restricted family caregivers from visiting their dying loved ones in residences, long-term care institutions, and hospitals. As a result, family members were faced with critical decisions that could easily lead to ethical dilemmas and moral distress.

AIM

This study aimed to understand better the experience of ethical dilemmas among family caregivers who lost a loved one.

METHDS

We interviewed twenty bereaved family caregivers and analysed their narratives using Interpretative phenomenological analysis.

RESULTS

Our analysis suggests that family caregivers struggled with their multiple responsibilities (collective, relational, and personal) and had to deal with the emotional cost of their choices. Results display three emerging themes describing the experience of ethical struggles: (1) Flight or fight: Struggling with collective responsibility; (2) Being torn apart: Assuming relational responsibility and (3) "Choosing" oneself: The cost of personal responsibility.

DISCUSSION/CONCLUSION

Results are discussed and interpreted using an ethical, humanistic, and existential conceptual framework.

Exploring experiences of moral injury and distress among health care workers during the Covid-19 pandemic

OBJECTIVE

Health care workers have been exposed to a variety of practical and emotional challenges because of the Covid-19 pandemic, leaving them vulnerable to experiencing moral injury and distress. However, there is currently sparse research which directly explores such experiences. This study aimed to explore and characterise the experiences and impacts of moral injury and distress among health care workers during the pandemic.

METHODS

Twenty semi-structured interviews were conducted with health care workers employed across both mental and physical health care services. Interviews were analysed from a critical realist perspective using thematic analysis.

RESULTS

Three key themes were identified: attitudes towards moral injury, experiences of moral injury and consequences of moral injury. Participants appeared to identify with the idea of acting against their morals to varying extents based on their job roles. Participants experienced a range of potentially morally injurious and distressing events throughout the pandemic and many ultimately felt that they provided sub-standard levels of care due to extreme pressures on services. Detrimental impacts upon wellbeing were commonly reported, including high levels of emotional distress and feelings of guilt and shame. Some reported a loss of enthusiasm for their job and a desire to leave the profession entirely.

CONCLUSION

Moral injury and distress presents a real concern for staff wellbeing and retention within the profession. During and beyond the Covid-19 pandemic, there is an urgent need for health care providers to implement wider strategies to target moral injury and distress, and support staff within health care settings.