1
|
Wachtler C, Bergqvist M, Bastholm-Rahmner P, Gustafsson LL, Schmidt-Mende K. COVID-19 guidelines and media influenced ethical care in nursing homes. Nurs Ethics 2024:9697330241268923. [PMID: 39177002 DOI: 10.1177/09697330241268923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The early phase of the COVID-19 pandemic affected nursing homes and their residents heavily. Guidelines on how to mitigate the virus's spread and ensuring safe healthcare delivery were continually evolving. Concurrently, nursing homes faced intense media scrutiny. This challenging environment severely impacted registered nurses and physicians employed within these facilities. AIM To understand the ethical challenges experienced by registered nurses and physicians working in nursing homes during the COVID-19 pandemic. RESEARCH DESIGN Qualitative descriptive research using thematic analysis. PARTICIPANTS AND RESEARCH CONTEXT Individual online interviews with four registered nurses and eight physicians clinically active at nursing homes in Sweden. ETHICAL CONSIDERATIONS The study was approved by the Swedish Ethical Review Authority. All participants provided written consent. RESULTS Registered nurses and physicians working in nursing homes perceived ethical challenges stemming from early COVID-19 pandemic guidelines and media coverage. The main theme generated was 'Struggling to maintain professional and ethical standards under pressure' incorporating two subthemes: 'Guidelines developed without the profession put pressure on staff' and 'Media's biased reporting was perceived as unethical and undermined care'. Guidelines from the authorities were considered as developed without professional involvement. It made them difficult to adhere to without deviating from professional and ethical compasses. Media coverage adversely influenced relatives' perceptions, resulting in mistrust towards physicians' and registered nurses' in delivering optimal care for the residents. CONCLUSIONS Resilient care in nursing homes necessitates the collaborative development of guidelines involving registered nurses and physicians, particularly amidst crises. Moreover, it is vital to provide support to registered nurses navigating ethical dilemmas, especially during pandemics. Guidelines and principles for care during a crisis should be development with professional involvement, be transparent, and be available to the public, to promote neutral media coverage. Future research is crucial to enhance ethical standards and tackle challenges in this context.
Collapse
|
2
|
Miljeteig I, Førde R, Rø KI, Bååthe F, Bringedal BH. Moral distress among physicians in Norway: a longitudinal study. BMJ Open 2024; 14:e080380. [PMID: 38803245 PMCID: PMC11129035 DOI: 10.1136/bmjopen-2023-080380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses. DESIGN Longitudinal survey. SETTING Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021. PARTICIPANTS 1499 physicians in 2004 and 2316 physicians in 2021. MAIN OUTCOME MEASURES The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work. RESULTS Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements. CONCLUSION In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.
Collapse
Affiliation(s)
- Ingrid Miljeteig
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department for Research and Development, Bergen Hospital Trust, Bergen, Norway
| | - Reidun Førde
- Center for Medical Ethics, University of Oslo Faculty of Medicine, Oslo, Norway
- Institute for Studies of the Medical Profession, Oslo, Norway
| | | | - Fredrik Bååthe
- Institute for Studies of the Medical Profession, Oslo, Norway
- Institute of Stress Medicine, Gothenburg, Sweden
| | | |
Collapse
|
3
|
Oelhafen S, Monteverde S, Trachsel M. Overestimating prevalence? Rethinking boundaries and confounders of moral distress. J Health Psychol 2024:13591053241253233. [PMID: 38780231 DOI: 10.1177/13591053241253233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Moral distress denotes a negative reaction to a morally challenging situation. It has been associated with adverse outcomes for healthcare professionals, patients and healthcare institutions. We argue that existing definitions, along with measures of moral distress, compromise the validity of empirical research. First, the definition and measurement of moral distress conflate moral events and psychological distress, even though they are distinct phenomena that should be assessed independently. Second, in many studies, there is a lack of clarity in distinguishing between moral and non-moral events. Finally, prior research on moral distress often overlooks the substantial body of evidence demonstrating the impact of diverse work-related factors, beyond moral events, on both distress and job retention. These challenges might undermine the effectiveness of interventions aimed at alleviating moral distress. We outline a comprehensive research agenda that encompasses conceptual clarifications, the refinement of data collection instruments, the design of studies and the application of appropriate statistical methods.
Collapse
Affiliation(s)
| | - Settimio Monteverde
- Bern University of Applied Sciences, Switzerland
- University of Zurich, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital Basel (USB), University Psychiatric Clinics (UPK) Basel, Geriatric University Hospital Felix Platter Basel, and University Children's Hospital Basel, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
| |
Collapse
|
4
|
Houle SA, Ein N, Gervasio J, Plouffe RA, Litz BT, Carleton RN, Hansen KT, Liu JJW, Ashbaugh AR, Callaghan W, Thompson MM, Easterbrook B, Smith-MacDonald L, Rodrigues S, Bélanger SAH, Bright K, Lanius RA, Baker C, Younger W, Bremault-Phillips S, Hosseiny F, Richardson JD, Nazarov A. Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev 2024; 108:102377. [PMID: 38218124 DOI: 10.1016/j.cpr.2023.102377] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.
Collapse
Affiliation(s)
- Stephanie A Houle
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Research Directorate, Veterans Affairs Canada, Charlottetown, Canada
| | - Natalie Ein
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | - Julia Gervasio
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Rachel A Plouffe
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, University of Dundee, Dundee, UK
| | - Brett T Litz
- Department of Psychiatry, Boston University, Boston, USA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, USA; Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | | | - Kevin T Hansen
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Jenny J W Liu
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | | | - Walter Callaghan
- Department of Anthropology, University of Toronto, Toronto, Canada
| | | | - Bethany Easterbrook
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Canada
| | | | - Sara Rodrigues
- The Atlas Institute for Veterans and Families, Ottawa, Canada
| | | | | | - Ruth A Lanius
- Department of Psychiatry, Western University, London, Canada
| | - Clara Baker
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - William Younger
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | | | | | - J Don Richardson
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Anthony Nazarov
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.
| |
Collapse
|
5
|
Rushton CH, Hanson GC, Boyce D, Holtz H, Nelson KE, Spilg EG, Robillard R. Reliability and validity of the revised Rushton Moral Resilience Scale for healthcare workers. J Adv Nurs 2024; 80:1177-1187. [PMID: 37772644 DOI: 10.1111/jan.15873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/30/2023]
Abstract
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.
Collapse
Affiliation(s)
- Cynda H Rushton
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ginger C Hanson
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Danielle Boyce
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heidi Holtz
- School of Nursing, Barnes College of Nursing, St. Louis, Missouri, USA
| | - Katie E Nelson
- Center for Indigenous Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Edward G Spilg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | |
Collapse
|
6
|
Nazarov A, Forchuk CA, Houle SA, Hansen KT, Plouffe RA, Liu JJW, Dempster KS, Le T, Kocha I, Hosseiny F, Heesters A, Richardson JD. Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition. Eur J Psychotraumatol 2024; 15:2306102. [PMID: 38334695 PMCID: PMC10860421 DOI: 10.1080/20008066.2024.2306102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/14/2023] [Indexed: 02/10/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Anthony Nazarov
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Canada
| | - Callista A. Forchuk
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Stephanie A. Houle
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Research Directorate, Veteran Affairs Canada, Charlottetown, Canada
| | - Kevin T. Hansen
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Rachel A. Plouffe
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Jenny J. W. Liu
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Kylie S. Dempster
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Tri Le
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Ilyana Kocha
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | | | - Ann Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, Canada
- The Institute for Education Research, University Health Network, Toronto, Canada
- Joint Centre for Bioethics, University of Toronto, Toronto, Canada
- The Michener Institute, University Health Network, Toronto, Canada
- The Wilson Centre, University Health Network, Toronto, Canada
| | - J. Don Richardson
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Canada
- St. Joseph’s Operational Stress Injury Clinic, St. Joseph’s Health Care London, London, Canada
| |
Collapse
|
7
|
Peters R, Rogge A, Dunst J, Freitag-Wolf S, Schmalz C. Moral Distress in Radiation Oncology: Insights From Residents in Germany. Adv Radiat Oncol 2024; 9:101378. [PMID: 38405316 PMCID: PMC10885585 DOI: 10.1016/j.adro.2023.101378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/12/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Being challenged by circumstances that force one to act in discordance with one's moral compass can lead to moral distress. The phenomenon has been widely investigated among nurses. This study was designed to shed some light on the situation of resident physicians in radiation oncology. Methods and Materials To gain insight into moral distress among residents in radiation oncology, a web-based questionnaire was developed and distributed throughout Germany. Participants were asked to evaluate possible burdensome situations and different options for relief. To outline the main issues of moral distress, an exploratory factor analysis was conducted. Relief options were examined by frequencies. Results The factor analysis yielded lack of time, contradiction between patient request and indication, nonmedical interests, and decisions between curative treatment and best supportive care as main issues for the 84 participants. Support from supervisors and senior physicians, as well as exchanges with resident colleagues were indicated as forms of relief. Professional support, such as ethics consultations, structured conversation groups (Balint), or psychological case supervisions, were rated as less helpful, although most participants reported a lack of experience with these. Conclusions The results are in accordance with existing assumptions that moral distress among physicians is mainly due to uncertainty. Regarding radiation oncology residents in particular, moral distress seems to be related to uncertainty in decisions and conflicts about treatment options. Although senior physicians and supervisors present important role models in dealing with moral distress, professional services such as ethics consultations offer an opportunity for relief that can still be expanded.
Collapse
Affiliation(s)
- Ricarda Peters
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Annette Rogge
- Paracelsus Nordseeklinik Helgoland, Helgoland, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institut für Medizinische Informatik und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Claudia Schmalz
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| |
Collapse
|
8
|
Morley G, Sankary LR. Re-examining the relationship between moral distress and moral agency in nursing. Nurs Philos 2024; 25:e12419. [PMID: 36748963 DOI: 10.1111/nup.12419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/21/2022] [Accepted: 01/14/2023] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Georgina Morley
- Nursing Ethics Program, Center for Bioethics, Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lauren R Sankary
- Neuroethics Program, Center for Bioethics, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
9
|
Fourie C, Campelia G. Moral Distress and the Marginalization of Nurses. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:132-134. [PMID: 38236848 DOI: 10.1080/15265161.2023.2278555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
|
10
|
Kim DT, Shelton W, Applewhite MK. Clinician Moral Distress: Toward an Ethics of Agent-Regret. Hastings Cent Rep 2023; 53:40-53. [PMID: 38131494 DOI: 10.1002/hast.1544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well-understood in terms of what Bernard Williams calls "agent-regret." We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience.
Collapse
|
11
|
Stoeklé HC, Billard D, Bennouna J, Beuzeboc P, Hervé C. "Emergency" multidisciplinary team meeting in cancer: a first feedback from a care team. J Transl Med 2023; 21:767. [PMID: 37904183 PMCID: PMC10614336 DOI: 10.1186/s12967-023-04652-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/23/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Henri-Corto Stoeklé
- Department of Ethics and Scientific Integrity, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - David Billard
- Department of Oncology and Supportive Care, Supportive Care Center, Line Renaud Institute, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - Jaafar Bennouna
- Department of Oncology and Supportive Care, Supportive Care Center, Line Renaud Institute, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - Philippe Beuzeboc
- Department of Oncology and Supportive Care, Supportive Care Center, Line Renaud Institute, Foch Hospital, 40 rue Worth, 92150, Suresnes, France
| | - Christian Hervé
- Department of Ethics and Scientific Integrity, Foch Hospital, 40 rue Worth, 92150, Suresnes, France.
- Medical School, Paris Cité University, Paris, France.
- Department of One Health and Global Health, Medical School, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Montigny-le-Bretonneux, France.
| |
Collapse
|
12
|
Morley G, Bena JF, Morrison SL, Albert NM. Sub-categories of moral distress among nurses: A descriptive longitudinal study. Nurs Ethics 2023; 30:885-903. [PMID: 37141428 DOI: 10.1177/09697330231160006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard "narrow" definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown. RESEARCH AIMS To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument. RESEARCH DESIGN A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6 weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data. PARTICIPANTS Registered nurses from four hospitals within one large healthcare system in Midwest United States. ETHICAL CONSIDERATIONS IRB approval was obtained. RESULTS 246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by "other" distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation. CONCLUSIONS Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.
Collapse
Affiliation(s)
- Georgina Morley
- Nursing Ethics Program, Center for Bieothics, Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic Health System, Cleveland, OH, USA
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic Health System, Cleveland, OH, USA
| | - Shannon L Morrison
- Quantitative Health Sciences, Cleveland Clinic Health System, Cleveland, OH, USA
| | - Nancy M Albert
- Office of Nursing Research and Innovation, Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic Health System, Cleveland, OH, USA
| |
Collapse
|
13
|
Sommerlatte S, Lugnier C, Schoffer O, Jahn P, Kraeft AL, Kourti E, Michl P, Reinacher-Schick A, Schmitt J, Birkner T, Schildmann J, Herpertz S. Mental burden and moral distress among oncologists and oncology nurses in Germany during the third wave of the COVID-19 pandemic: a cross-sectional survey. J Cancer Res Clin Oncol 2023; 149:6211-6223. [PMID: 36700979 PMCID: PMC9878480 DOI: 10.1007/s00432-023-04580-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/07/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE There is evidence for mental burden and moral distress among healthcare workers during the pandemic. However, there is scarcity of analyses regarding possible correlations of mental burden and moral distress in this context. This study provides data to quantify mental burden and possible associations with moral distress among physicians and nurses working in oncology in Germany. METHODS We conducted a cross-sectional online survey with physicians and nurses working in oncology in Germany between March and July 2021. Next to sociodemographic characteristics and working conditions, mental burden and moral distress were assessed using standardized instruments. Binary multivariate logistic regression using the enter method was performed in order to explore the relationship between mental burden and moral distress. RESULTS 121 physicians and 125 nurses were included in the study. Prevalence of clinically relevant depressive symptoms, anxiety, somatic symptoms, burnout symptoms and moral distress was 19.2, 14.5, 12.7, 46.0 and 34.7% in physicians and 41.4, 24.0, 46.8, 46.6 and 60.0% in nurses respectively. Mental burden was significantly associated with moral distress, being female/diverse, younger age < 40 and increase in workload. Nurses who felt sufficiently protected from COVID-19 reported significantly less moral distress. CONCLUSION To improve pandemic resilience, there is a need to ensure safe working environment including psychosocial support. Further evidence on risk and protective factors for moral distress is needed to be able to develop and implement strategies to protect healthcare workers within and beyond the pandemic.
Collapse
Affiliation(s)
- Sabine Sommerlatte
- Faculty of Medicine, Institute for History and Ethics of Medicine, Interdisciplinary Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Celine Lugnier
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Olaf Schoffer
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Patrick Jahn
- Health Services Research Working Group, Department of Internal Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Anna-Lena Kraeft
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Eleni Kourti
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Patrick Michl
- Department of Medicine, Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Anke Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Thomas Birkner
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Jan Schildmann
- Faculty of Medicine, Institute for History and Ethics of Medicine, Interdisciplinary Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Stephan Herpertz
- Department of Psychosomatic Medicine and Psychotherapy, LWL-University Clinic, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|
14
|
Seidlein AH. Moral Distress: Allgegenwärtig, erschöpfend erforscht und nun? Pflege 2023; 36:187-188. [PMID: 37482772 DOI: 10.1024/1012-5302/a000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Affiliation(s)
- Anna-Henrikje Seidlein
- Institut für Ethik und Geschichte der Medizin, Universitätsmedizin Greifswald, Deutschland
| |
Collapse
|
15
|
Epstein EG, Hurst AR, Bourne D, Marshall MF. Measure for Measure: Condemning the Actor and Not the Fault. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:66-68. [PMID: 37011352 DOI: 10.1080/15265161.2023.2186530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
16
|
Matisonn H, de Vries J, Hoare J. Capturing Moral Distress as a Global Phenomenon in Healthcare. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:82-84. [PMID: 37011341 DOI: 10.1080/15265161.2023.2186520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
17
|
Jackson-Meyer K, Symons X, Duffee C. Moral Distress as Critique: Going beyond 'Illegitimate Institutional Constraints'. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:79-82. [PMID: 37011362 DOI: 10.1080/15265161.2023.2186519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
18
|
Shen L, Zhang H, Yang Y, Liao S, Wang Y. Instruments of Moral Distress: An Analysis Based on Scientificity and Application Value. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:89-91. [PMID: 37011348 DOI: 10.1080/15265161.2023.2186527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Lijun Shen
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Hui Zhang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Yongguang Yang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Shixiu Liao
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
- National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Yuming Wang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
- National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| |
Collapse
|
19
|
de Bie AL, Abdool S, Butler J, Campbell A, Hassanein M, Hillman S, Makkar J, Maurice R, Robertson J, Szego MJ, Langlois D. Ethics Debriefs and Moral Distress: What are we Doing? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:74-77. [PMID: 37011345 DOI: 10.1080/15265161.2023.2186524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
| | | | | | | | | | - Sean Hillman
- Unity Health Toronto
- University of Toronto
- Lakeridge Health
| | | | | | - Jamie Robertson
- Unity Health Toronto
- University of Toronto
- St. Joseph's Health System
| | | | | |
Collapse
|
20
|
Morley G, Sankary LR. Moral Distress and Justifiable Constraints on Moral Agency. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:77-79. [PMID: 37011361 DOI: 10.1080/15265161.2023.2186518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
21
|
Applewhite M, Giordano J. Moral Distress in Military Medicine: Toward Analysis of, and Approach to Measurement, Prevention and Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:86-88. [PMID: 37011358 DOI: 10.1080/15265161.2023.2186515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
22
|
Ulrich CM, Grady C. Measuring Moral Distress and its Various Sources. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:63-65. [PMID: 37011355 PMCID: PMC10214211 DOI: 10.1080/15265161.2023.2186512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
23
|
Boxell L, Lanphier E. Measuring Moral Distress: Improving the Tools by Educating Clinicians. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:61-63. [PMID: 37011360 DOI: 10.1080/15265161.2023.2186517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
| | - Elizabeth Lanphier
- Cincinnati Children's Hospital Medical Center
- University of Cincinnati College of Medicine
| |
Collapse
|
24
|
Prentice TM. Moral Distress Tools: Not Just a Question of What but Why Are We Measuring? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:59-61. [PMID: 37011353 DOI: 10.1080/15265161.2023.2186531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Trisha M Prentice
- Royal Children's Hospital
- Murdoch Children's Research Institute
- University of Melbourne
| |
Collapse
|
25
|
Kok N, Zegers M, Hoedemaekers C, van Gurp J. Moral Distress: The Context of Measurement. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:71-74. [PMID: 37011357 DOI: 10.1080/15265161.2023.2186514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Niek Kok
- Radboud University Medical Center
| | | | | | | |
Collapse
|
26
|
Usset T, Fantus S. Moral Distress Is a Systemic Problem Requiring Organizational Solutions. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:84-86. [PMID: 37011343 DOI: 10.1080/15265161.2023.2186522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
| | - Sophia Fantus
- The University of Texas Arlington School of Social Work
| |
Collapse
|
27
|
Wocial LD. Evolving Measures of Moral Distress: Imperfect Does Not Mean Irrelevant. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:68-71. [PMID: 37011344 DOI: 10.1080/15265161.2023.2186523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
|
28
|
Fiester A. Reducing Moral Distress by Teaching Healthcare Providers the Concepts of Values Pluralism and Values Imposition. THE JOURNAL OF CLINICAL ETHICS 2023; 34:296-306. [PMID: 37991731 DOI: 10.1086/727437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
AbstractThere is a clear need for interventions that reduce moral distress among healthcare providers (HCPs), given the high prevalence of moral distress and the far-ranging negative consequences it has for them. Healthcare ethics consultants are frequently called upon to manage moral distress, especially among nursing staff. Recently, researchers have both broadened the definition of moral distress and demarcated subcategories of the phenomenon with the intent of creating more targeted and effective interventions. One of the most frequently occurring subcategories of moral distress in this new taxonomy has been labeled "moral-constraint distress," though scholars have argued that not all constraints on HCPs' moral agency are inappropriate given the often-competing healthcare values of patients, families, and clinical staff. To attempt to reduce the instances of moral distress in cases in which the constraints on HCPs' moral agency are justified, we propose an intervention that focuses on shifting the HCPs' "frame of reference" on moral-constraint distress, teaching HCPs how to distinguish unjustified and justified constraints on their moral agency. The anchors of this blueprint for reducing moral-constraint distress are the philosophical concepts of "values pluralism" and "values imposition." The rationale for this intervention is that, in situations where the constraint on moral agency is justified but the experience of moral distress could nevertheless be severe, the emphasis needs to be on helping the HCP to "think differently" rather than "act differently."
Collapse
|
29
|
Barr P. Moral Distress and Burnout in NICU Nurses. J Obstet Gynecol Neonatal Nurs 2022; 51:441-449. [PMID: 35661651 DOI: 10.1016/j.jogn.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/30/2022] Open
Abstract
The objectives of this study were to factor analyze the Moral Distress Scale-Revised (MDS-R) in NICU nurses and to evaluate the relationships among dimensions of the MDS-R and the demoralization, exhaustion, and loss of motive dimensions of the Burnout Measure (BM). A total of 142 NICU nurses completed modified pen-and-paper versions of the MDS-R and BM. Exploratory and confirmatory factor analyses showed that the MDS-R-14 was a relatively good fit for the data. The compromised care dimension predicted BM demoralization (β = 0.24) and exhaustion (β = 0.22), the futile care dimension predicted BM exhaustion (β = 0.18), and the untruthful care dimension predicted BM demoralization (β = .25). Strategies to mitigate moral distress and resulting burnout in NICU nurses should address futile care, compromised care, and untruthful care.
Collapse
|