Moral sensitivity and moral distress in Iranian critical care nurses

Design and psychometric properties of an instrument to assess metacognition in moral reasoning in medicine

AIM

The present study aims at designing and assessing the psychometric properties of MCMR instruments to lead the medical ethics education to further goals and more definite steps.

DESIGN

This is a cross sectional study.

METHOD

This study was conducted in two phases; identifying the items and designing the instrument. In the preliminary phase, the qualitative study was carried out using conventional content analysis method. In the second phase, psychometric evaluation of instrument was done using face and content validity, construct validity and reliability.

RESULTS

On the first phase of this study, 135 items were identified. After determining face and content validity, 111 items reached the stage of exploratory factor analysis. This instrumental analysis indicated the existence of 74 items and ten factors whose variance of the total is explained as 46.883%. Cronbach's alpha value was 0/75. And the intra-cluster correlation coefficient was 0.808.

The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization

The present study was conducted to determine the relation between nurses’ moral distress and the ethical climate in selected hospitals of the Iranian Social Security Organization (ISSO). This descriptive-analytical correlational study was conducted in 6 hospitals under the coverage of the Iranian Social Security Organization in 2016. Three hundred nurses were selected by convenience sampling method. Data were gathered using Corley’s Standard Moral Distress and Olson’s Hospital Ethical Climate Scales. Data were analyzed using SPSS software version 19.

The mean score of the nurses’ moral distress was 1.94 ± 0.66, which is considered moderate. The mean score of ethical climate was 88.97, indicating desirable ethical climate in these hospitals. The frequency score of moral distress had a unilateral reverse correlation with the total score of ethical climate as well as its dimensions, including colleagues, patients, hospitals and physicians. The score of the intensity of nurses’ moral distress also had a unilateral reverse correlation with the total score of ethical climate and the scores of the hospital and physicians dimensions.

These results emphasized the importance of creating a positive ethical climate to decrease moral distress as well as the need for professional interventions to increase support in moral issues.

Moral sensitivity components identified among nurses from Intensive Care Units

OBJECTIVE

to identify ethical problems from the components of moral sensitivity among nurses of Intensive Care Units.

METHOD

qualitative, exploratory-descriptive study developed in a hospital in the South of Brazil with 19 nurses working in intensive care units through semi-structured interviews that were analyzed through discursive textual analysis.

RESULTS

ethical education, dialogue, relationships with other health team members, professional autonomy, knowledge, personal values, effective communication, leadership and patients' positive outcomes were identified as important components of nurses' moral sensitivity, and comprise the domains of moral consciousness, benevolent motivation, and spontaneous moral perception.

FINAL CONSIDERATIONS

the components of moral sensitivity identified in this study facilitate nurses' instrumentalization in the face of decision making and ethical problems in the intensive care setting.

Experiences of pre-hospital emergency medical personnel in ethical decision-making: a qualitative study

Background

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service (EMS) personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with every day, ethical decision-making (EDM) has become an inevitable challenge.

Methods

The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method.

Results

The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight (8) sub-categories signifying participants’ experiences with regard to EDM.

Conclusion

According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties.

The effectiveness of narrative writing on the moral distress of intensive care nurses

BACKGROUND

Nursing is a profession that has always been accompanied with common ethical concerns. There are some evidences which indicate that narrative writing on traumatic experiences may improve an individual's emotional health.

OBJECTIVE

This study aimed to determine the effectiveness of narrative writing on moral distress of nurses working in intensive care unit.

RESEARCH DESIGN

This study was a clinical trial with pre- and post-test design. The frequency and intensity of moral distress was measured by a valid and reliable questionnaire (Corely) at baseline and after 8 weeks. The intervention group was asked to write about their deepest emotions and stressful experiences in the intensive care unit for 8 weeks.

PARTICIPANTS AND RESEARCH CONTEXT

Using consensus sampling, 120 nurses of intensive care unit and neonatal intensive care unit of the teaching hospitals (in Iran) were invited to and were randomly allocated into the intervention and control groups.

ETHICAL CONSIDERATIONS

Participation was voluntary, data were anonymized, and the confidentiality of the participating nurses and their institutions maintained. The ethical approval was obtained from an IRB or research ethics committee.

FINDINGS

In total, 106 nurses completed the trial consisting of 87.75% females. The mean work experience of nurses in the intervention and control groups was 7.21 ± 4.96 and 8.28 ± 5.45 years, respectively. Independent t-test showed no statistical difference neither in the intensity of moral distress (P = 0.8), nor in its frequency (P = 0.5) between the two groups.

DISCUSSION

As nurses constantly face ethical tensions, moral distress is a phenomenon that results from the different situations of critical care units. Their concern about receiving negative feedback from the managerial level may have influenced the outcome of the intervention.

CONCLUSION

Narratives writing by the nurses showed no effect on reducing the intensity and frequency of moral distress. It seems that due to the intensity of moral distress in clinical settings, we need to test variety solutions to reduce the problem.

Severity and frequency of moral distress among midwives working in birth centers

BACKGROUND

When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems.

RESEARCH OBJECTIVE

The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers.

RESEARCH DESIGN

This study is a descriptive cross-sectional research. Researcher-made questionnaire was used to gather data.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census.

ETHICAL CONSIDERATIONS

Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained.

FINDINGS

The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010).

DISCUSSION

The midwives' moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses.

CONCLUSION

After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures.

Evaluating ethical sensitivity in surgical intensive care nurses

BACKGROUND AND AIM

Surgical intensive care nurses should have ethical sensitivity allowing them to identify ethical issues in order that they can recognize them and make the right decisions. This descriptive study was conducted with the aim of evaluating the ethical sensitivity of surgical intensive care nurses.

MATERIALS AND METHODS

The research was carried out with the participation of 160 nurses in six Turkish hospitals, four state, one university, and one private. The data were collected using the "Nurse Description Form" developed by the researcher and the "Ethical Sensitivity Questionnaire." The percent, mean, standard deviation, median, minimum and maximum values, significance test for the difference between two means, variance analysis, Mann-Whitney U test, and Kruskal-Wallis Variance Analysis test were used to evaluate the data.

ETHICAL CONSIDERATIONS

Ethical commission permission and the corporate permission of the hospitals were received before conducting the research.

RESULTS

It was determined that the ethical sensitivities of surgical intensive care nurses were moderate based on the Ethical Sensitivity Questionnaire total score and subdimension score averages. A statistical difference was determined between the Ethical Sensitivity Questionnaire total score of surgical intensive care nurses and the institution where they worked, the period of working in the occupation, and the period of working in the intensive care unit (p < 0.05).

CONCLUSION

Based on the results of the research, the organization of training and studies devoted to the elimination of ethical sensitivity differences between institutions and workers is suggested.

Health care reform in Iran: Implications for nurses' moral distress, patient rights, satisfaction and turnover intention

AIM

The aim of the present study was to assess the implications of Iran's recent health care reforms on nurses' experience of moral distress, their perceptions of the respect for patient rights and the relationship of these variables to job and income dissatisfaction and turnover intention.

BACKGROUND

Health systems around the world are reforming themselves to adapt to meeting the future needs of increasing patient care to an ever-growing population.

METHODS

This was a cross-sectional correlational study. The participants were 276 nurses at six large private and public hospitals in Tehran, Iran.

FINDINGS

Negative correlations were reported between turnover intention and respecting patient rights (r = -0.560, p < 0.001), satisfaction with job (r = -0.710, p < 0.001) and satisfaction with income (r = -0.226, p < 0.001). The correlation between moral distress intensity (r = 0.626, p < 0.001) and frequency (r = 0.701, p < 0.001) was positive with turnover intention.

CONCLUSIONS

Moral distress was significantly correlated to poor respect for patient rights, poor job satisfaction and income satisfaction and was a major predictor of turnover intention.

IMPLICATIONS FOR NURSING MANAGEMENT

Health system reform must take into account the concomitant increasing workload and its negative impact in order to ensure that reform does not lead to unintentional detrimental outcomes of increased moral distress, decreased satisfaction and increased turnover rates among nursing personnel.

Effects of ethical leadership on nurses' service behaviors

BACKGROUND

Nurses' service behaviors have critical implications for hospitals. However, few studies had adequate ethical considerations of service behaviors and accounted for how organizational or individual antecedents can induce nurses to engage in service behaviors. In addition, they mainly focused on the one side of role-prescribed or extra-role service behavior.

OBJECTIVE

This study aims to explore the chained mediation effect of ethical climate and moral sensitivity on the relationship between organizational ethical leadership and nurses' service behaviors and to examine the relationship, from a comparative view, of the role-prescribed service behavior and extra-role service behavior.

METHODS

In all, 476 nurses from three tertiary hospitals were investigated with the Ethical Leadership Scale, Ethical Climate Scale, Moral Sensitivity Questionnaire and Service Behavior Questionnaire. Structural equation modeling was adopted to analyze the data. SPSS and Mplus statistical software was used in the data analysis.

ETHICAL CONSIDERATIONS

Approval was obtained from the Ethics Committee at School of Nursing, Hebei Medical University. Data privacy and confidentiality were maintained and assured by obtaining subjects' informed consent to participate in the research before data collection.

RESULTS

The effects of ethical leadership on nurses' service behaviors are mediated by two variables in turn: ethical climate and nurses' moral sensitivity. Ethical climate and moral sensitivity partially mediated the relationship between ethical leadership and nurses' role-prescribed service behavior and fully mediated the relationship between ethical leadership and nurses' extra-role service behavior.

CONCLUSION

Organizational ethical leadership positively affected ethical climate, which positively affected nurses' moral sensitivity and affected both their role-prescribed service behavior and extra-role service behavior.

Impact of moral sensitivity on moral distress among psychiatric nurses

Background:

Moral distress occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation. Not only external factors such as lack of staff but also internal ones affect moral distress. Moral sensitivity, which is thought of as an advantage of nurses, could effect moral distress, as nurses being unaware of existing ethical problems must feel little distress.

Objectives:

To examine the impact of moral sensitivity on moral distress among psychiatric nurses, and affirm the hypothesis that nurses with higher moral sensitivity will suffer moral distress more than nurses with less moral sensitivity in two different samples.

Ethical consideration:

The study obtained ethical approval from the Research Ethics Committee of the Faculty of Medicine at Mie University (# 1111, 20.4.2010), and by the Turku University Ethics Board (29.5.2012). Permissions to undertake the study was obtained from the in two hospital districts and in one city (§ 48/4.10.2012, § 63/4.9.2012, 51/2012 27.8.2012). Informed consent was not formally obtained, because the questionnaire was anonymously reported by the participants who volunteered to answer. The participants responded voluntarily and anonymously.

Methods:

An anonymous questionnaire containing the Revised Moral Sensitivity Questionnaire and the Moral Distress Scale for Psychiatric nurses was conducted to 997 nurses in 12 hospitals in Japan, and 974 nurses in 10 hospitals in Finland after obtaining of approval by research ethics committees. Data were analyzed using a multi-group structural equation model analysis.

Findings:

A set of analyses imply that the association of moral sensitivity with moral distress is significant and similar between Japan and Finland, whereas the factor structures of moral sensitivity and moral distress may be partially different.

Discussion:

The result of this study may indicate that nurses with high moral sensitivity can sense and identify moral problems, but not resolve them. Therefore, supporting nurses to solve ethical problems, not benumbing them, can be important for better nursing care and prevention of nurses’ resignation.

Conclusion:

Moral sensitivity and moral distress were positively correlated among psychiatric nurses in both Japan and Finland, although the participating nurses from the two countries were different in qualification, age, and cultural background. Nurses with high moral sensitivity suffer from moral distress.

A Second-Order Confirmatory Factor Analysis of the Moral Distress Scale-Revised for Nurses

Background:

Moral distress is a growing problem for healthcare professionals that may lead to dissatisfaction, resignation, or occupational burnout if left unattended, and nurses experience different levels of this phenomenon.

Objectives:

This study aims to investigate the factor structure of the Persian version of the Moral Distress Scale–Revised in intensive care and general nurses.

Research design:

This methodological research was conducted with 771 nurses from eight hospitals in the Mazandaran Province of Iran in 2017. Participants completed the Moral Distress Scale–Revised, data collected, and factor structure assessed using the construct, convergent, and divergent validity methods. The reliability of the scale was assessed using internal consistency (Cronbach’s alpha, Theta, and McDonald’s omega coefficients) and construct reliability.

Ethical considerations:

This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences.

Findings:

The exploratory factor analysis ( N = 380) showed that the Moral Distress Scale–Revised has five factors: lack of professional competence at work, ignoring ethical issues and patient conditions, futile care, carrying out the physician’s orders without question and unsafe care, and providing care under personal and organizational pressures, which explained 56.62% of the overall variance. The confirmatory factor analysis ( N = 391) supported the five-factor solution and the second-order latent factor model. The first-order model did not show a favorable convergent and divergent validity. Ultimately, the Moral Distress Scale–Revised was found to have a favorable internal consistency and construct reliability.

Discussion and conclusion:

The Moral Distress Scale–Revised was found to be a multidimensional construct. The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. Since the convergent and divergent validity of the scale were not confirmed in this study, further assessment is necessary in future studies.

Relationship between moral distress and ethical climate with job satisfaction in nurses

BACKGROUND:

Moral distress and ethical climate are important issues in the workplace that appear to affect people's quality of work life.

OBJECTIVES:

This study was conducted to determine the relationship of moral distress and ethical climate to job satisfaction in critical care nurses.

MATERIALS AND METHODS:

This descriptive-correlation study was conducted on 142 critical care nurses, selected from five social security hospitals in north Iran through census sampling. Data were collected using a demographic questionnaire, the Moral Distress Scale-Revised, the Olson's Hospital Ethical Climate Survey, and the Brayfield and Rothe Job Satisfaction index.

ETHICAL CONSIDERATIONS:

The research project was approved by the Ethics Committee of Mazandaran University of Medical Sciences and the Medical Deputy of the Social Security Organization.

FINDINGS:

The mean scores obtained by the critical care nurses for moral distress, ethical climate, and job satisfaction were 87.02 ± 44.56, 3.51 ± 0.53, and 62.64 ± 9.39, respectively. Although no significant relationships were observed between moral distress and job satisfaction, the relationship between ethical climate and job satisfaction was statistically significant (p < 0.05).

CONCLUSION:

Identifying ethical stressors in the workplace and giving proper feedback to the authorities to eliminate these factors and improve the ethical climate in these workplaces can help enhance job satisfaction in nurses and lead to higher quality care.

Psychometric evaluation of the Moral Distress Risk Scale: A methodological study

BACKGROUND:

Moral distress is a kind of suffering that nurses may experience when they act in ways that are considered inconsistent with moral values, leading to a perceived compromise of moral integrity. Consequences are mostly negative and include physical and psychological symptoms, in addition to organizational implications.

OBJECTIVE:

To psychometrically test the Moral Distress Risk Scale.

RESEARCH DESIGN:

A methodological study was realized. Data were submitted to exploratory factorial analysis through the SPSS statistical program.

PARTICIPANTS AND RESEARCH CONTEXT:

In total, 268 nurses from hospitals and primary healthcare settings participated in this research during the period of March to June of 2016.

ETHICAL CONSIDERATIONS:

This research has ethics committee approval.

FINDINGS:

The Moral Distress Risk Scale is composed of 7 factors and 30 items; it shows evidence of acceptable reliability and validity with a Cronbach's α = 0.913, a total variance explained of 59%, a Kaiser-Meyer-Olkin = 0.896, and a significant Bartlett <0.001.

DISCUSSION:

Concerns about moral distress should be beyond acute care settings, and a tool to help clarify critical points in other healthcare contexts may add value to moral distress speech.

CONCLUSION:

Psychometric results reveal that the Moral Distress Risk Scale can be applied in different healthcare contexts.