Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care

Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study

BACKGROUND

While several studies have been performed on turnover intention among nurses, limited studies have considered the ethical perspectives on turnover intention among haemodialysis nurses. The purpose of this study was to clarify the impact of ethical factors, namely ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses.

METHODS

This cross-sectional research was conducted between July and August 2017. A total of 148 haemodialysis nurses were invited to participate in the study by convenience sampling from 11 general and university hospitals in South Korea. Data were analysed using SPSS for t-test, one-way analysis of variance, Pearson's correlation coefficients, and multiple regression analysis.

RESULTS

In the final regression model, the adjusted R-squared significantly explained 34.6% of the variance in turnover intention (F = 22.534, p < .001) when moral distress related to physician practice (β = 0.310, p = .001) and ethical climate related to the hospital climate (β = - 0.253, p = .003) and manager (β = - 0.191, p = .024) were included. Following the stepwise multiple regression process, all subdomains related to moral sensitivity were excluded due to no statistical significance in the final regression model.

CONCLUSION

To reduce turnover intention among haemodialysis nurses, hospitals and managers should pay attention to haemodialysis nurses' moral distress originating from physicians' practice and improve their ethical climate. Additionally, it is required that the impact of moral sensitivity on turnover among nurses working in diverse care settings be examined further.

Systematic scoping review on moral distress among physicians

BACKGROUND

Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians.

METHODS

A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows.

RESULTS

A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions.

CONCLUSIONS

Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

Mitigating Moral Distress in Leaders of Healthcare Organizations: A Scoping Review

GOAL

Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership.

METHODS

Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles.

PRINCIPAL FINDINGS

Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress.

PRACTICAL APPLICATIONS

Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.

Continuation of Hemodialysis in a Patient With Global Hypoxic Brain Injury: Ethical Considerations and Factors That May Influence Decision Making

Survivors of an out-of-hospital cardiac arrest are at a high risk of mortality and morbidity especially when there is resultant global hypoxic brain injury. In these situations, the patient's degree of neurologic recovery may be uncertain and family decision making is often difficult. Decision making may also be complicated by the age of the patient and one's underlying cultural and spiritual beliefs stressing the importance of patient- and family-centered care. In this article, this clinical case demonstrates the challenges in decision making and highlights the importance of communication among the health care team and the family to align the patient's goals, values, and preferences in light of a poor neurological prognosis.

Burnout Among Nephrologists in the United States: A Survey Study

Rationale & Objective

Burnout decreases job satisfaction and leads to poor patient outcomes but remains underinvestigated in nephrology. We explored the prevalence and determinants of burnout among a sample of nephrologists.

Study Design

Cross-sectional.

Setting & Participants

The nephrologists were approached via the American Medical Association Physicians Masterfile, National Kidney Foundation listserv, email, and social media between April and August 2019. The predictors were demographics and practice characteristics. The outcome was burnout, defined as responding “once a week” or more on either 1 of the 2 validated measures of emotional exhaustion and depersonalization or both.

Analytical Approach

Participant characteristics were tabulated. Responses were compared using χ² tests. Multivariable logistic regression was used to estimate the odds ratios (ORs) of burnout for risk factors. Free text responses were thematically analyzed.

Results

About half of 457 respondents were 40-59 years old (n=225; 49.2%), and the respondents were more predominantly men (n=296; 64.8%), US medical graduates (n=285; 62.4%), and in academic practice (n=286; 62.6%). Overall, 106 (23.2%) reported burnout. The most commonly reported primary drivers of burnout were the number of hours worked (n=27; 25.5%) and electronic health record requirements (n=26; 24.5%). Caring for ≤25 versus 26-75 patients per week (OR, 0.34; 95% confidence interval [95% CI], 0.15-0.77), practicing in academic versus nonacademic settings (OR, 0.33; 95% CI, 0.21-0.54), and spending time on other responsibilities versus patient care (OR, 0.32; 95% CI, 0.17-0.61) were each independently associated with nearly 70% lower odds of burnout after adjusting for age, sex, race, and international medical graduate status. The free text responses emphasized disinterested health care systems and dissatisfaction with remuneration as the drivers of burnout.

Limitations

Inability to precisely capture response rate.

Conclusions

Nearly one-quarter of the nephrologists in our sample reported burnout. Future studies should qualitatively investigate how the care setting, time spent on electronic medical records, and hours of clinical care drive burnout and explore other system-level drivers of burnout in nephrology.

Moral Distress and Moral Injury in Nephrology During the COVID-19 Pandemic

Summary: Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.

Ethical Duties of Nephrologists: When Patients Are Nonadherent to Treatment

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.

Priority-setting dilemmas, moral distress and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway

Background:

The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction.

Aim:

Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway.

Research design:

A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020.

Ethical considerations:

Ethical approval granted by the Regional Research Ethics Committee in Western Norway (131421).

Findings:

Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful.

Discussion:

By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority.

Conclusion:

Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms.

Ethics of kidney care in the era of COVID-19

The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.

Ethical challenges in nephrology: a call for action

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.