Moral Distress and Intention to Leave the Profession: Lithuanian Nurses in Municipal Hospitals

PURPOSE

The purpose of this study was to describe the level of moral distress experienced by nurses, situations that most often caused moral distress, and the intentions of the nurses to leave the profession.

METHODS

A descriptive, cross-sectional, correlational design was applied in this study. Registered nurses were recruited from five large, urban Lithuanian municipal hospitals representing the five administrative regions in Lithuania. Among the 2,560 registered nurses, from all unit types and specialities (surgical, therapeutic, and intensive care), working in the five participating hospitals, 900 were randomly selected to be recruited for the study. Of the 900 surveys distributed, 612 questionnaires were completed, for a response rate of 68%. Depending on the hospital, the response rate ranged from 61% to 81%. Moral distress was measured using the Moral Distress Scale-Revised (MDS-R). The MDS-R is designed to measure nurses' experiences of moral distress in 21 clinical situations. Each of the 21 items is scored using a Likert scale (0-4) in two dimensions: how often the situation arises (frequency) and how disturbing the situation is when it occurs (intensity). On the Likert scale, 0 correlates to situations that have never been experienced, and 4 correlates to situations that have occurred very often.

RESULTS

Among the 612 participants, 206 (32.3%) nurses reported a low level of moral distress (mean score 1.09); 208 (33.9%) a moderate level of distress (mean score 2.53), and 207 (33.8%) a high level of distress (mean score 3.0). The most commonly experienced situations that resulted in moral distress were as follows: "Carrying out physician's orders for what I consider to be unnecessary tests and treatments" (mean score 1.66); "Follow the family's wishes to continue life support even though I believe it is not in the best interest of the patient" (mean score 1.31); and "Follow the physician's request not to discuss the patient's prognosis with the patient or family" (mean score 1.26). Nurses who had a high moral distress level were three times more likely to consider leaving their position compared with respondents who had a medium or low moral distress level (8.7% and 2.9%, respectively; p < .05).

CONCLUSIONS

Our findings provide evidence on the association between moral distress and intention to leave the profession. Situations that may lead health professionals to be in moral distress seem to be mainly related to the unethical work environment.

CLINICAL RELEVANCE

The findings of this study reported that moral distress plays a role in both personal and organizational consequences, including negative emotional impacts upon employees.

Rethinking Private-Public Partnership in the Health Care Sector: The Case of Municipal Hospital affiliation

By the late 1950s, New York City's public hospital system-more extensive than any in the nation-was falling apart, with dilapidated buildings and personnel shortages. In response, Mayor Robert Wagner authorized an affiliation plan whereby the city paid private academic medical centers to oversee training programs, administrative tasks, and resource procurement. Affiliation sparked vigorous protest from critics, who saw it as both an incursion on the autonomy of community-oriented public hospitals and the steamrolling of private interests over public ones. In the wake of the New York City fiscal crisis of 1975, however, the viability of a purely public hospital system withered, given the new economic climate facing the city. In its place was a new institutional form: affiliation and the public-private provision of public health care.

Health policy making through operative actions: a case study of provider capacity reduction in a public safety-net system

This article describes and assesses the implications of policy decisions affecting health provider capacity in the Los Angeles County municipal safety-net health system from 1980 to 2000. Although never articulated in law or a county ordinance, the county pursued a sustained and discernable policy of cost reductions that affected capacity at King/Drew Medical Center from 1980 to 2000 without the input of beneficiaries or their advocates. Year after year, the county reduced personnel, supplies, and available beds either by reducing formal budgets or through operative actions of facility administrators that prevented the implementation of formally approved expenditures. This policy appears to have undermined the hospital system's mission of providing health services to at-risk populations with nowhere else to go. Decision making during the two decades under study revealed a decision-making pattern that challenged traditional models of policy decision making.

[The improvement of manpower support of municipal hospitals]

The article demonstrates the importance of analysis of improvement of implementation of manpower support of municipal hospitals in the framework of development of planning their activities. The optimal identification of demand in manpower and other types of resources is considered.

Identification and understanding of pre-term birth at Kintampo Municipal Hospital: a qualitative cross-sectional study

Up to 42% of nearly 10 million under five deaths occur in neonates with prematurity being a principal cause. This paper presents the outcome of a cross sectional qualitative study conducted among 14 hospital staff engaged in infant care in Kintampo, Ghana. Confidential interviews were used to evaluate their knowledge and practice of preterm care. Critical steps in caring for normal and preterm infants were ranked as adequate, satisfactory or inadequate if 75% or more, 50% to 74%, or less than 50% of the health workers completed them respectively. For term infants, adequate care was provided in terms of cleaning and wrapping, weighing, and initiating early feeds. Knowledge and practice were inadequate in relation to preterm care. Educational interventions emphasizing preterm care are recommended as an essential package for rural health workers. A newborn assessment tool was designed to address the gap in data collection identified during the study.

A two-dimensional equity proposal for self-sufficiency in municipal safety-net hospitals

This article advances a two-dimensional equity approach for self-sufficiency in municipal safety-net hospitals that will strengthen provider self-sufficiency and protect the safety-net mission of providing a dignified floor of health services to the most disadvantaged members of the society. The model responds to the failure of current delivery strategies to effectively cope with the changing market configurations in safety-net systems that have eliminated the possibility of cross-subsidization which has long been the mainstay of safety-net systems. The identified pathway to self sufficiency is made up of (1) a differential service delivery framework which includes a two-tier patient system, uniform standards of care and service levels, and the creation of a community health campus; (2) independent sector ownership; and (3) intergovernmental policy actions restricting ownership of safety-net hospitals to nonprofit entities. Although this model is explained by demonstrating potential application in safety-net hospitals, it is believed that the model is applicable in ambulatory care settings. Future work can focus on the construction of an ambulatory variation of the model and the empirical testing of the hospital and ambulatory models.

[Three centuries of surgery at Colţea Hospital]

The authors present the evolution of surgery at Colţea Hospital during the last three centuries. After a brief history of the Colţea hospital and its masters surgeons, the attention is drawn on the masters efforts to optimize the care, equipment and surgery techniques, things that became of national and world-wide importance.

Mass General makes its survey findings public

Hospital takes two-pronged approach, dealing with transparency while pursuing performance improvement. In addition to a copy of The Joint Commission survey, facility answers key questions and provides regular updates on web site. Policy of openness helps generate staff buy-in for PI initiatives.

[Assessment of medical waste management in a Palestinian hospital]

We studied medical waste management in a Palestinian hospital in the West Bank and the role of municipality in this management. In general, "good management practices" were inadequate; there was insufficient separation between hazardous and non-hazardous wastes, an absence of necessary rules and regulations for the collection of wastes from the hospital wards and the on-site transport to a temporary storage location inside and outside the hospital and inadequate waste treatment and disposal of hospital wastes along with municipal garbage. Moreover, training of personnel was lacking and protective equipment and measures for staff were not available. No special landfills for hazardous wastes were found within the municipality.

Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting

Only 50% of New Yorkers aged 50 and over reported ever being screened for colorectal cancer by any modality according to a recent household survey. The objective of this investigation was to assess the impact of a hospital-based intervention aimed at eliminating health care system barriers to timely colorectal cancer screening at Lincoln Medical Center, a large, urban public hospital in one of the nation's poorest census tracts. We conducted a retrospective analysis of all colonoscopies performed over an 11-month period, during which a multi-pronged intervention to increase the number of screening colonoscopies took place. Two "patient navigators" were hired during the study period to provide continuity for colonoscopy patients. A Direct Endoscopic Referral System (DERS) was also implemented. Enhancements to the gastrointestinal (GI) suite were also made to improve operational efficiency. Immediately following the introduction of the patient navigators, there was a dramatic and sustained decline in the broken appointment rates for both screening and diagnostic colonoscopy (from 67% in May of 2003 to 5% in June of 2003). The likelihood of keeping the appointment for colonoscopy after the patient navigator intervention increased by nearly 3-fold (relative risk = 2.6, 95% CI 2.2-3.0). The rate of screening colonoscopies increased from 56.8 per month to 119 per month. The screening colonoscopy coverage provided by this facility among persons aged 50 and over in surrounding Zip codes increased from 5.2 to 15.6% (RR 3.0, 95% CI 1.9-4.7). Efforts to increase the number of screening colonoscopies were highly successful, due in large part to the influence of patient navigators, a streamlined referral system, and GI suite enhancements. These findings suggest that there are significant health-care system barriers to colonoscopy that, when addressed, could have a significant impact on screening colonoscopy rates in the general population.

Randomized clinical trial of a postdischarge pharmaceutical care program vs. regular follow-up in patients with heart failure

OBJECTIVE

To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).

METHOD

A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit.

RESULTS

134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group.

CONCLUSIONS

Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

The development of municipal general hospitals in English county boroughs in the 1930s

When thinking of spurs to hospital development in the first half of the last century, it would be easy to assume that the greatest watershed was provided by the 1946 National Health Service Act. In this article, however, we focus on an earlier and often overlooked piece of legislation, which had a perhaps equally significant impact on the development of hospitals in England and Wales. This was the 1929 Local Government Act, which changed both the ownership and the focus of many of the largest hospitals in the country. As Robert Pinker has observed, the act “radically altered the percentage distribution of hospital beds in the public sector”. Such observations notwithstanding, municipal medicine in the 1930s has not received the historical attention it deserves, an omission which this article seeks in part to remedy. The terms of the act in respect of hospital development were permissive, and the extent to which local authorities acted had a great effect on the way in which their municipal hospital services developed, and hence the beds and facilities available at the time of the nationalization of the health services. The reaction of local authorities to the act, however, depended partly on their own choices, and partly on constraints over which they had less control.

[National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla]

OBJECTIVE

To identify the changes brought about by various national and international factors in an intercultural hospital of the municipality of Cuetzalán, Puebla.

MATERIAL AND METHODS

A case study was conducted during 2000 and 2001 in two Intercultural Hospitals of Mexico; the Cuetzalán Hospital in Puebla and the Jesús María Hospital in Nayarit State. Data were collected by means of 72 semi-structured interviews with allopathic therapists, indigenous therapists, and authorities of the different health care levels. Moreover, documental research was carried out on national policies for indigenous peoples as well as on indigenist policies. These policies were related with the five organizational stages of the hospital. State authorities gave their permission and interviewees signed informed consent.

RESULTS

The hospital was created in 1958 by the Ministry of Health as a biomedical institution, in agreement with the integrationist indigenist policies going on at the time. It remained so during the beginning of the administration by the National Indigenist Institute. In 1990, the new participative indigenist policy trends and the creativity and sensitivity of some authorities, under the influence of international strategies, helped to transform the hospital into an Intercultural Hospital (offering both types of medicine, indigenous and allopathic) with regional coverage. In 2000, the devolution of the hospital to the State Ministry of Health, based on financial rather than socio-cultural considerations, caused the temporary loss of its intercultural character. The last stage as an Integral Hospital with Traditional Medicine (from 2003 onwards) was due to a combination of state official initiatives and the new political stance acquired by the Mexican indigenous movement. The hospital is now part of a regional project of five such hospitals officially denominated Integral Hospitals with Traditional Medicine, to be financed by the Puebla-Panama Plan of regional development.

CONCLUSIONS

Our results confirmed that health organizations follow a historical process in which selected national and international forces open opportunities to promote intercultural health models that respond to the needs of indigenous populations. Despite the formerly held belief that traditional and scientific medicines were incompatible, this study demonstrates the viability of intercultural health care models that may become a real possibility in the country, based on new conventions to establish alternative and intercultural health services, thereby setting an example for other regions and countries. The English version of this paper is available at: http://www.insp.mx/salud/index.html.