Reflective Debriefing: A Social Work Intervention Addressing Moral Distress among ICU Nurses

Implementation of a routine post-shift debriefing program in ICU aiming at quality-of-care improvement: A primary analysis of feasibility and impacts

OBJECTIVES

This report describes the implementation of a clinical debriefing (CD) program in intensive care units (ICU) and analyses its feasibility and its impact on staff well-being.

DESIGN

Observational study.

SETTING

From April to September 2023, post-shift CDs were run once a week in 2 out of 7 units in our department, using an adapted version of the DISCOVER-PHASE tool. CD sessions were performed face-to-face with volunteer members of the multidisciplinary ICU team.

MAIN OUTCOME MEASURES

After 6 months, a survey assessing the satisfaction of the debriefed teams was conducted. The impact of CD on staff well-being was assessed using three validated questionnaires (Maslach Burnout Inventory, Ways of Coping Checklist, Professional Quality of Life Scale) administered in the 7 units before and after the CD period.

RESULTS

A total of 44 CDs were performed, lasting 15 (4-35) min. There were 6 (1-9) attendees per CD, mainly nurses (64.6%). Discussions focused mainly on basic problems related to dysfunctional material, communication and organization inside the team. The two debriefed teams were satisfied of the program and gave 9, 8 and 8 out of 10 on a visual analogical scale for the climate of confidence of the DC, their organisation, and their ability to improve working conditions and quality of care, respectively. Subscores at the three questionnaires assessing staff well-being before and after the CD period were similar, whether teams experienced CD or not.

CONCLUSIONS

Implementing of post-shift debriefings in our ICU was feasible and well accepted. More prolonged programs are probably needed to demonstrate benefits on staff well-being.

IMPLICATIONS FOR CLINICAL PRACTICE

This report offers elements that other teams can use to successfully conduct post-shift debriefings and to plan future research on longer-term programs.

Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations

In pediatric critical care, nurses are the primary caregivers for critically ill children and are particularly vulnerable to moral distress. There is limited evidence on what approaches are effective to minimize moral distress among these nurses. To identify intervention attributes that critical care nurses with moral distress histories deem important to develop a moral distress intervention. We used a qualitative description approach. Participants were recruited using purposive sampling between October 2020 to May 2021 from pediatric critical care units in a western Canadian province. We conducted individual semi-structured interviews via Zoom. A total of 10 registered nurses participated in the study. Four main themes were identified: (1) "I'm sorry, there's nothing else": increasing supports for patients and families; (2) "someone will commit suicide": improving supports for nurses: (3) "Everyone needs to be heard": improving patient care communication; and (4) "I didn't see it coming": providing education to mitigate moral distress. Most participants stated they wanted an intervention to improve communication among the healthcare team and noted changes to unit practices that could decrease moral distress. This is the first study that asks nurses what is needed to minimize their moral distress. Although there are multiple strategies in place to help nurses with difficult aspects of their work, additional strategies are needed to help nurses experiencing moral distress. Moving the research focus from identifying moral distress towards developing effective interventions is needed. Identifying what nurses need is critical to develop effective moral distress interventions.

Wellness Strategies Among Bad Outcomes and Complications

Surgery of the chest is high stakes, and adverse events are common. Given the frequency and severity of such complications, cardiothoracic surgeons are at particularly high risk of becoming second victims. Even though our primary commitment as doctors is to take care of our patients, surgeons may fall into the emotional and intellectual trap of taking on the whole responsibility of a patient's poor outcome. This viewpoint may lead the physician to develop a heightened self-doubt, greater insecurity, and imposter syndrome, further affecting their ability to prevent complications and tackle difficult cases in the future.

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

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

Proactive debriefing to promote wellbeing in intensive care nurses: A protocol

BACKGROUND

The dynamic, rewarding, yet challenging environment of the intensive care unit is experienced in extremes by intensive care nurses. To ensure intensive care nurses can continue to fulfil their professional roles and responsibilities, careful consideration and promotion of collective and individual wellbeing is required. Regular proactive debriefing provides an opportunity to commune, connect, and reflect on the challenging nature of clinical work and is a potential intervention to aid in the promotion of wellbeing.

AIM/OBJECTIVE

This study aims to collaboratively develop, implement, and evaluate a proactive debriefing intervention, which will target the promotion of nurses' wellbeing.

STUDY PLAN

This hybrid effectiveness-implementation study will use a pretest/post-test design to test a codesigned proactive debriefing intervention on the wellbeing of nurses working in a large quaternary intensive care unit. This research will be conducted in two phases. Phase one will consist of focus groups and a codesign workshop. Phase two surrounds the implementation and analysis of the codesigned intervention.

Development of a Midwifery Student Peer Debriefing Tool: An interpretive descriptive study

BACKGROUND

Psychosocial traumatisation associated with giving birth, can occur in those present with the woman giving birth, a phenomenon known as vicarious trauma. It has been identified that there are currently no interventions available for midwifery students who have experienced vicarious trauma following difficult birth experiences.

OBJECTIVE

To explore whether the counselling intervention developed by Gamble et al. (2005), can be adapted for midwifery students to be appropriately and feasibly used as a counselling intervention with peers who have experienced midwifery practice-related vicarious trauma.

DESIGN

Interpretive descriptive methodology.

SETTING

This study was set at two Australian universities from which pre-registration midwifery courses are delivered.

PARTICIPANTS

The work of reviewing the original tool and adapting it for use by and with midwifery students associated with this project was conducted by a key stakeholder group of seven representative midwifery students and five midwifery academics.

METHODS

Ethics were approved. Data were collected via one face to face and two online conversations using the Microsoft Teams™ platform. Reflexive Thematic analysis were applied to revise the tool following each round of data collection and to finalise the adaptation of the intervention for its new intended purpose.

RESULTS

The Midwifery Student Peer Debriefing Tool is presented as a six-step intervention that guides the midwifery student through a process of debriefing with their peer. The feasibility of the tool resulted in an overarching theme labelled "I want this to mean something" and captures the therapeutic power of peer debriefing toward a meaningful outcome that fostered growth, and a deeper understanding of the profession.

CONCLUSION

Vicarious trauma is widely recognised as a core reason for midwives and midwifery students leaving the workforce. The peer debriefing tool helps midwifery students move through the process of recovering from adversity but also fostered learnings about midwifery practice and the profession.

Interventions to support critical care nurse wellbeing: A scoping review

INTRODUCTION

Recruitment and retention of qualified nurses in critical care is challenging and has been further exacerbated by the COVID-19 pandemic. Poor staff wellbeing, including sickness absence and burnout contribute to a high staff turnover and staff shortages. This scoping review charts wellbeing interventions targeting nurses who work in adult critical care.

METHODS

Following the Joanna Briggs Institute scoping review methodology, five databases were searched: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Embase, Ovid PsycINFO, and the Cochrane Library alongside a search for grey literature targeting national and international critical care nurse organisations. Primary research studies (qualitative, quantitative and mixed methods), as well as quality improvement studies and policy frameworks published from January 1997 to September 2022 were included. Studies conducted outside an adult critical care setting or not including adult critical nurses were excluded. Extracted data were charted using a series of tables.

RESULTS

26 studies met the inclusion criteria. Most of the interventions targeted personal rather than organisational strategies, focusing on resilience training, mindfulness-based interventions, and other psychological approaches. One intervention was not evaluated. Most of the rest of the studies reported their interventions to improve wellbeing. However, only one study evaluated the intervention for longer than six months.

CONCLUSION

Current evidence identified that critical care nurse wellbeing is an international concern affecting recruitment and retention. Most available wellbeing interventions take a psychological, personal approach. However, these may not address the complex interaction of organisational factors which impact adult critical care nurses.

IMPLICATIONS FOR CLINICAL PRACTICE

Further work is needed to identify and evaluate organisational approaches to improving wellbeing and to evaluate wellbeing interventions over a longer period of time. Critical care nurses should be included in the design of future wellbeing interventions.

Moral Distress and Moral Injury in Military Healthcare Clinicians: A Scoping Review

Introduction

Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member.

Methods

A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies.

Results

A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis.

Discussion

This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.

Developing an evidence-and ethics-informed intervention for moral distress

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic's trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach to develop a moral distress intervention-proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness.

Intensive care unit nurses' perceptions of debriefing after critical incidents: A qualitative descriptive study

BACKGROUND

Intensive care unit (ICU) nurses are exposed to critical incidents daily at their workplace, which may have long-term physical and psychological impacts. Despite the growing evidence supporting clinical debriefing in health care to prevent these impacts, a scarcity of literature exists to support its use in the adult intensive care setting.

OBJECTIVES

The objective of this study was to explore nurses' perceptions of clinical debriefing after critical incidents in an adult ICU.

METHODS

A qualitative descriptive design was utilised. Thematic analysis of data from individual semistructured interviews with six ICU nurses was undertaken.

FINDINGS

In this study, two themes were identified. Firstly, participants valued hot debriefing after critical incidents for the key reasons of having an opportunity to reflect on and learn from a critical incident and reduce normalisation of stressful situations. Secondly, when logistical factors such as communication, timing, and location were not considered, the attendance at debriefings was negatively influenced. Participants identified that ICU nurses commonly prioritised patient tasks over attending a debrief; therefore, teamwork and flexibility with logistics was crucial.

CONCLUSIONS

Hot debriefing, of a short duration and close to the time of the event, was valued and played an important role in staff wellbeing and self-care, contributing to preventing self-blame and normalisation of stressful situations. A clearer definition of the term along with greater recognition of types of events that could be considered critical incidents is required for staff support after critical incidents in the complex intensive care setting.

Addressing Health Care Workers' Mental Health: A Systematic Review of Evidence-Based Interventions and Current Resources

Background. Mental health is declining in health care workers. Objectives. To provide a comprehensive assessment of intervention literature focused on the support and treatment of mental health within the health care workforce. Search Methods. We searched online databases (e.g., Medline, PsycINFO). Selection Criteria. We selected manuscripts published before March 2022 that evaluated the target population (e.g., nurses), mental health outcomes (e.g., burnout, depression), and intervention category (e.g., mindfulness). Data Collection and Analysis. Of 5158 publications screened, 118 interventions were included. We extracted relevant statistics and information. Main Results. Twenty (17%) earned study quality ratings indicating design, analysis, and implementation strengths. Randomized controlled trials were used by 52 studies (44%). Thirty-eight percent were conducted in the United States (n = 45). Ninety (76%) reported significant changes, and 46 (39%) reported measurable effect sizes. Multiple interventions significantly reduced stress (n = 29; 24%), anxiety (n = 20; 17%), emotional exhaustion or compassion fatigue (n = 16; 14%), burnout (n = 15; 13%), and depression (n = 15; 13%). Authors' Conclusions. Targeted, well-designed mental health interventions can improve outcomes among health care workers. Public Health Implications. Targeted health care‒focused interventions to address workers' mental health could improve outcomes within this important and vulnerable workforce. (Am J Public Health. 2024;114(S2):S213-S226. https://doi.org/10.2105/AJPH.2023.307556).

Nurses' perceptions about bereavement care in critical care units: A qualitative study

AIM

To explore critical care nurses' perceptions of bereavement nursing care in critical care settings at a tertiary hospital in Singapore.

BACKGROUND

Grief and bereavement are stressful life experiences associated with significant health problems. Critical care nurses play important roles in supporting bereaved family members, and their self-competence affects the quality of the care they deliver. Exploring critical care nurses' perceptions of bereavement nursing care is thus essential.

METHODS

An exploratory descriptive qualitative study design was adopted. A total of 16 nurses were recruited. One-on-one interviews were conducted using a semi-structured interview guide and were audio-recorded. The data collected were analysed using thematic analysis. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

FINDINGS

Five themes surfaced in the study, namely, family responses, holistic care, psychological impact, self-competence and organisational dynamics.

CONCLUSION

This study highlighted the key roles of critical care nurses in providing bereavement care, how their self-competence impacts care delivery and the significant impacts of organisational policies on their capacity to provide care.

IMPLICATIONS FOR NURSING AND NURSING POLICY

Nursing administrators should provide enhanced organisational support to critical care nurses who provide bereavement nursing care, and implement training work plans to ensure nurses are adequately prepared to provide culturally appropriate care. Strategies should be introduced to reduce administrative burden, expand the role of critical care nurses in providing bereavement nursing care, and establish and enlist role models as drivers of bereavement nursing care.

Experiences of Pain Management Nurses during the COVID-19 Pandemic: A Qualitative Study

BACKGROUND

The knowledge and skills of pain management nurses positions them well to manage people's pain and provide critical services to patients with COVID-19.

AIM

To understand the personal and professional experiences and the support pain management nurses received during the COVID-19 pandemic.

METHODS

Between July 2020 and 2021, data were collected through semi-structured telephone interviews from members of the American Society for Pain Management Nursing. Content analysis was used.

RESULTS

Eighteen pain management nurses who worked during the early stages of the pandemic were interviewed. Three main categories were identified: experiencing stress and burden, pain management strategies changed, learning to cope with support. Pain management nurses reported fear of exposure, difficulties with staff shortages, the complex social milieu, and how pain management took a backseat to other symptoms of COVID-19. They coped through support from their colleagues, organizational leaders, and community members. Pain management nurses provided recommendations for future care of patients' pain during a pandemic.

CONCLUSIONS

Pain management nurses shared their professional and personal experiences and the support they received while managing patients' pain during the COVID-19 pandemic. Their experiences provided findings on the importance of pain management and to support nurses during personal and professional vulnerabilities during crises. Key recommendations on the care of patients' pain in future pandemics included developing expertise in pain management and health-related emergencies; engaging nurses in supportive mental health services, infectious disease testing, and vaccine efforts; and planning for surge capacity to reach out to underserved people living with pain.

Day to Day and Environmental Risk Factors for Psychological Distress Among Healthcare Workers: A Mixed Methods Analysis

OBJECTIVE

Despite a growing literature on mental health among clinical staff during COVID-19, factors shaping distress for nonclinical staff are understudied and may be driven by inequalities at work. We aimed to discuss the role of workplace factors in shaping psychological distress for a diverse group of clinical, nonclinical, and other health and hospital workers (HHWs).

METHODS

This convergent parallel mixed-methods study with HHWs in a US hospital system included an online survey ( n = 1127) and interviews ( n = 73) collected from August 2020 to January 2021. We thematically analyzed interviews; findings informed log binomial regression estimating risk factors for severe psychological distress (Patient Health Questionnaire - 4 item version [PHQ-4] scores of 9 or greater).

RESULTS

Qualitatively, day-to-day stressors fostered fear and anxiety, and concerns about work environments manifest as betrayal and frustration with leadership. Distress was associated with burnout, financial concerns, and feeling betrayed or unsupported by the institution and leadership. Staff in service versus clinical roles had higher risk for severe distress (adjusted prevalence ratio = 2.04, 95% confidence interval = 1.13-2.66); HHWs receiving workplace mental health support had lower risk (adjusted prevalence ratio = 0.52, 95% confidence interval = 0.29-0.92.

CONCLUSIONS

Our mixed-methods study underscores how the pandemic brought inequalities to the surface to increase distress for vulnerable HHWs. Workplace mental health activities can support HHWs now and during future crises.

An educational program of reducing moral distress (PRMD) in nurses; designing and evaluating

BACKGROUND

Moral distress is common phenomenon that has negative consequences on nurses, patients, and healthcare systems. This study aims to design and evaluate an educational program to reduce moral distress in nurses.

METHODS

This multiphase mixed-method study was done in three stage on February 2021 in Shiraz/Iran. In pre-implementation stage, a content analysis study was conducted on 12 participants were interviewed using purposive sampling and then the program was designed according to qualitative data, panel of expertise and literature review according the seven steps of Ewles and Sminett's model and implemented in one group on 40 nurses using a quasi-experimental design. In Post-Implementation stage, effectiveness of program was evaluated through quantitative and qualitative methods. Quantitative data were gathered by Hamric's 21-question moral distress questionnaire analyzed via SPSS v.25 and analysis of variance repeated measures test. Also, a content analysis study was conducted on 6 PRMD participants using purposive sampling. In Program evaluation stage, convergence of quantitative and qualitative data and the effects of the program were examined. Trustworthiness of qualitative data was accomplished by Lincoln and Guba criteria.

RESULTS

First quantitative study revealed the causes of moral distress consisted of deficiency in professional competency, unsuitable organizational culture, personal factors, environmental and organizational factors, management factors, insufficiencies in proficient and efficient communication and nurses' observation of moral dilemma. Results of quantitative stage showed that there was a significant difference (p < 0.05) between the mean score of moral distress before, after, 1 and 2 months after the intervention. The participants in secondary qualitative stage, reported increasing their moral knowledge and skills, improving ethical climate, and moral empowerment.

CONCLUSION

The use of different educational tools and teaching methods and the participation of managers in designing strategies had a very effective role in the effectiveness of this educational program.

Impact of Case Review Debriefings on Moral Distress of Extracorporeal Membrane Oxygenation Nurses

BACKGROUND

Moral distress occurs when nurses know the ethically correct action to take but are restrained from taking it. Moral distress is prevalent in nurses who work in intense stress situations, as do extracorporeal membrane oxygenation nurses.

LOCAL PROBLEM

Nurses who work in critical care settings have higher levels of moral distress than nurses who work in other practice areas. The purpose of this project was to evaluate the effectiveness of case review debriefings on moral distress of extracorporeal membrane oxygenation nurses.

METHODS

Thirty-nine critical care registered nurses with specialty training in extracorporeal membrane oxygenation were invited to participate in this clinical improvement project. The intervention consisted of 2 case review debriefings. The Moral Distress Scale-Revised and the Moral Distress Thermometer were used to measure long-term and acute (short-term) moral distress.

RESULTS

Of a potential range of 0 to 336, the mean Moral Distress Scale-Revised score was 134.0 before intervention and 131.8 after intervention. The frequency of experiencing moral distress did not change after intervention, but the level of moral distress increased after intervention. Moral Distress Thermometer scores decreased for 80% of participants and increased for 20%. Five items related to perceptions of prolonging death and suffering were the most frequent causes of moral distress.

CONCLUSIONS

Developing strategies and providing opportunities to mitigate moral distress are crucial to a healthy future nursing workforce. Implications include the potential for improved patient care, decreased turnover rates and costs, and improved nurse satisfaction rates.

Effect of a Moral Distress Consultation Service on Moral Distress, Empowerment, and a Healthy Work Environment

BACKGROUND

 Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed.

OBJECTIVE

 To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation.

METHODS

 A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale.

RESULTS

 Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment.

CONCLUSIONS

 Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness.

Reflective Debriefs as a Response to Moral Distress: Two Case Study Examples

Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases ("Moral Distress Reflective Debriefs"). We discuss how the debriefing literature and other clinical ethics activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress.

Moral distress to moral success: Strategies to decrease moral distress

BACKGROUND

Moral distress, which is especially high in critical care nurses, has significant negative implications for nurses, patients, organizations, and healthcare as a whole.

AIM

A moral distress workshop and follow-up activities were implemented in an intensive care unit in order to decrease levels of moral distress and increase nurses' perceived comfort and confidence in ethical decision-making.

DESIGN

A quality improvement (QI) initiative was conducted using a pre- and post-intervention design. The program consisted of a four-hour interactive workshop, followed by two individual self-reflection activities at 2-3 weeks and 5-6 weeks after the workshop.

PARTICIPANTS

Critical care nurses working in a heart and vascular intensive care unit at a large academic medical center.

ETHICAL CONSIDERATIONS

This study was deemed to be a QI project by the institution's Institutional Review Board. Participation was voluntary.

FINDINGS

Nurses experienced a significant decrease in moral distress. The participants' average ethical confidence increased in four areas (ability to identify the conflicting values at stake, knowing role expectations, feeling prepared to resolved ethical conflict, and being able to do the right thing), with knowledge of role expectations and feeling prepared to resolve ethical conflict yielding statistically significant increases. Qualitative findings resulted in consistent themes related to causes of moral distress and ways nurses approached addressing moral distress.

DISCUSSION

This study reinforces previous evidence on moral distress and its causes in critical care nurses, and provides a mechanism for improving moral distress and ethical confidence.

CONCLUSIONS

This QI study demonstrates the effectiveness of an evidence-based program for decreasing critical care nurses' moral distress and increasing their ethical confidence. The strategies described in this paper can replicated by nursing leaders who wish to effect change at their local level, or adapted and expanded to other professions and clinical care units.

A systematic scoping review on the evidence behind debriefing practices for the wellbeing/emotional outcomes of healthcare workers

Introduction

Debriefings give healthcare workers voice through the opportunity to discuss unanticipated or difficult events and recommend changes. The typical goal of routine debriefings has been to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice. However, little research has investigated the effects of debriefings on the emotional experiences and well-being of healthcare workers. There is some evidence that debriefings are a multi-faceted and cost-effective intervention for minimising negative health outcomes, but their use is inconsistent and they are infrequently adopted with the specific intention of giving healthcare workers a voice. The purpose of this systematic scoping review is therefore to assess the scope of existing evidence on debriefing practices for the well-being and emotional outcomes of healthcare workers.

Methods

Following screening, 184 papers were synthesised through keyword mapping and exploratory trend identification.

Results

The body of evidence reviewed were clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices, and outcomes captured.

Discussion

The current review provides a clear map of our existing understanding and highlights the need for more systematic, collaborative and rigorous bodies of evidence to determine the potential of debriefing to support the emotional outcomes of those working within healthcare.

Systematic Review Registration

https://osf.io/za6rj.

Moral Distress in Canadian Intensivists: A Complex Interplay of Contextual and Relational Factors

BACKGROUND

Health-care professionals experience moral distress when they cannot act based on their moral beliefs because of perceived constraints. Moral distress prevalence is high among critical care (ICU) clinicians, but varies significantly between and within professions.

RESEARCH QUESTION

How can the interindividual variability in moral distress of Canadian ICU physicians be explained to inform future system-based interventions?

STUDY DESIGN

And Methods: We analyzed 135 free-text comments written by 83 of the 225 ICU physicians who participated in an online cross-sectional wellness survey. An interdisciplinary team of five investigators completed the thematic analysis of anonymized survey comments according to published guidelines.

RESULTS

Physicians identified contextual and relational factors that contributed to moral distress and work-related stress. Combined sources of distress created high work-related demands that were not always matched by equally high resources or mitigated by work-related rewards. An imbalance between demands and rewards could lead to undesirable individual and collective consequences.

INTERPRETATION

Moral distress is experienced variably by ICU physicians and is linked to contextual and relational factors. Future studies should evaluate modifiable factors such as team interactions and the role of professional rewards as mitigators of distress to bring new insights into strategies to improve ICU clinician wellness and patient care.

"People are more afraid of a dementia diagnosis than of death": The challenges of supporting advance care planning for persons with dementia in community settings

Improving early uptake of advance care planning (ACP) for persons with dementia and their families requires that staff in community-based settings feel armed and equipped to encourage and support this process. Yet few studies have explored whether staff within non-medical environments feel prepared to support early ACP engagement for persons with early-stage dementia and their families. Our qualitative interpretivist study aimed to fill this gap by facilitating, transcribing and thematically analyzing deliberations from three focus groups with 17 community-based staff. Our findings revealed four key barriers to ACP activation in community settings: (1) the stigma associated with the condition; (2) lack of knowledge about end-of-life concerns for persons with dementia; (3) uncertainties about managing complex family dynamics and (4) worries that opening up conversations about future care may lead to the expression of wishes that could not be actualized (e.g., dying at home). Our findings further revealed that ACP engagement was facilitated when staff expressed confidence in their capacities to gauge readiness, viewed themselves as guides rather than experts and had access to resources to supplement their knowledge. Reflexive training opportunities and access to materials and resources around end-of-life care for persons with dementia, could equip staff in these non-medical settings with the skills to engage in ongoing dialogue about future care issues with persons living with dementia and their families.

Burnout and coping strategies among nurses in Malaysia: a national-level cross-sectional study

OBJECTIVE

This national-level study aimed to determine the prevalence and risk factors of burnout, as well as the coping strategies among nurses in the Ministry of Health (MOH) Malaysia.

DESIGN

Using a complex sampling design, a two-stage stratified cluster sampling was performed to recruit MOH nurses between August and November 2019.

SETTING AND PARTICIPANTS

A total of 2428 nurses from 32 hospitals and 28 district health offices answered the questionnaires based on Maslach Burnout Inventory for Human Services and Brief COPE. Complex sampling analysis was applied.

OUTCOME MEASURES

The outcome of interest was the prevalence of burnout and its three domains of emotional exhaustion (EE), depersonalisation (DP) and low personal accomplishment. ORs using 95% CIs were calculated. Significant factors at the univariate level were entered into the multivariate logistic regression to identify independent predictors of burnout.

RESULTS

One in four (24.4%) nurses experienced burnout. Younger, single, and childless nurses had a higher prevalence of burnout. Shift working nurses were 1.6 times more likely to develop burnout. Those who performed >6 night shifts per month were 1.5 times more predisposed to burnout (95% CI 1.01 to 2.36; p<0.05). While encountering traumatic events at work led to 4.2 times (95% CI 2.31, 7.63; p<0.05) higher risk of burnout, those who received post-traumatic psychological support were better protected. The use of dysfunctional coping strategies was detrimental as it was positively correlated with EE and DP.

CONCLUSION

Addressing modifiable stressors of burnout at individual and institutional levels identified in this study can be potentially beneficial in reducing burnout and its undesirable effects among nurses. Interventions that promote positive coping strategies should be implemented. Organisational-driven efforts must target the improvement of work schedules for nurses and the establishment of a structured debriefing service for post-trauma counselling.

Addressing Moral Distress: lessons Learnt from a Non-Interventional Longitudinal Study on Moral Distress

BACKGROUND

Moral distress is prevalent within the neonatal intensive care unit (NICU) and can negatively affect clinicians. Studies have evaluated the causes of moral distress and interventions to mitigate its harmful effects. However, the effects of participating in moral distress studies have not been evaluated.

OBJECTIVE

To evaluate the impact of participation in a longitudinal, non-intervention research project on moral distress in the NICU.

DESIGN

Clinicians who previously participated in an 18-month longitudinal research study on moral distress at two NICUs were invited to complete a questionnaire on the impact of participation. The original study required regular completion of surveys that sought predictions of death, disability and the intensity/nature of moral distress experienced by clinicians caring for extremely preterm babies. Individual and unit-wide effects were explored. Free-text responses to open-ended questions were analyzed using inductive content analysis.

RESULTS

A total of 249/463 (53%) eligible clinicians participated. Participation in the original 18-month study was perceived as having a positive impact by 58% of respondents. Clinicians found articulating their views therapeutic (76%) and useful in clarifying personal opinions about the babies (85%). Free-text responses revealed the research stimulated increased reflection, validated feelings and increased dialogue amongst clinicians. Respondents generally did not find participation distressing (70%). However, a small number of physicians felt the focus of discussion shifted from the baby to the clinicians. Intensity and prevalence of moral distress did not significantly change over the 18-month period.

CONCLUSIONS

Participating in moral distress research prompted regular reflection regarding attitudes toward fragile patients, improving ethical awareness. This is useful in clarifying personal views that may influence patient care. Participation also enhanced communication around difficult clinical scenarios and improved provider satisfaction. These factors are insufficient to significantly reduce moral distress in isolation.

Fewer Patients per Nurse Does Not Offset Increased Nurse Stress Related to Treatment Uncertainty and Mortality in the Neonatal Intensive Care Unit

BACKGROUND

Many inpatient healthcare institutions' nurse staffing plans systematically assign fewer patients to nurses when patient acuity is high, but the impact of this strategy on components of nurse stress has not been thoroughly investigated.

PURPOSE

To examine the relationship between nurse-to-patient ratio assigned based on NICU patient acuity with the Nurse Stress Scale (NSS) subscales Death and Dying, Conflict with Physicians, Inadequate Preparation, Lack of Support, Conflict with Other Nurses, Work Load, and Uncertainty Concerning Treatment.

METHODS

A survey including the NSS tool items, demographic questions, and a question about nurse-to-patient ratio during the shift was administered. Cronbach's α, linear regression, and Spearman's correlation were used for data analysis.

RESULTS

Analysis of the 72 participating NICU nurses' survey responses showed fewer patients per nurse during the shift was negatively correlated with stress related to Death and Dying ( P < .001) and Uncertainty Concerning Treatment ( P = .002) subscale scores. This inverse relationship remained significant after controlling for education and years of experience.

IMPLICATIONS FOR PRACTICE

The observed higher stress can be inferred to be due to high patient acuity since fewer patients are assigned to nurses caring for high-acuity patients. Improvements in communication to nurses about patients' medical condition, treatment rationale, and information that should be conveyed to the family could reduce nurse stress from treatment uncertainty. Targeted education and counseling could help nurses cope with stress due to patient deaths.

IMPLICATIONS FOR RESEARCH

Interventions to reduce stress related to treatment uncertainty and death of patients among NICU nurses caring for high-acuity infants should be developed and evaluated.

Interventions to Reduce Nurses' Moral Distress in the Intensive Care Unit: An Integrative Review

BACKGROUND

Critical care nurses experience moral distress, the phenomenon of knowing the "right" thing to do but being unable to do so, at high rates; this contributes to attrition and has severe mental health impacts on nurses.

OBJECTIVE

The purpose of this integrative review was to determine if interventions to reduce moral distress have an effect on intensive care unit (ICU) nurses' moral distress levels.

METHODS

Three databases were searched, PubMed, APA PsycNet, and CINAHL, using the keywords "moral distress" AND nurs* AND reduc* AND ("intensive care" OR "critical care" OR ICU). Only experimental studies involving adult ICU nurses were included for a total of 6 studies.

RESULTS

Interventions fell into 3 categories: (1) educational interventions, (2) interventions to enhance the ICU environment, and (3) interventions to help nurses cope. Two studies detailing educational interventions demonstrated some reduction in moral distress. One study aimed to improve the ICU environment and showed some statistically significant reduction in moral distress. All 6 studies included some focus on coping, and 2 showed statistically significant reductions in moral distress.

DISCUSSION

Only a few studies have been conducted examining this issue. These studies had severe limitations, such as small sample sizes, attrition, and inadequate control groups. There were also few statistically significant results. These interventions should be reexamined using larger sample sizes, and other interventions should also be trialed. COVID-19 may have had a significant impact on this issue, and interventions may need to be refocused in the wake of the pandemic.

Expressions of Compassion Fatigue by Emergency Department Nurses Caring for Patients With Opioid and Substance Use Disorders

INTRODUCTION

The misuse of and addiction to opioids are a national public health crisis. The complexity of delivering patient care in emergency departments exposes nurses to stressful work situations with complex patient loads and increasing levels of compassion fatigue. Emergency nurses were asked about their feelings of compassion fatigue while caring for patients with opioid use and/or substance use disorders.

METHODS

Twenty-four focus groups with emergency nurses (N = 53) at a level I trauma center were conducted in late 2019 and early 2020 are used in this qualitative study using thematic analysis that identified 1 main theme of compassion fatigue with 3 subthemes (nurse frustration with addicted patients, emotional responses, and job satisfaction).

RESULTS

Findings highlight that emergency nurses working with patients with opioid use and/or substance use disorders are dealing with a number of negative emotional stressors and frustrations, which in turn has increased their levels of compassion fatigue. These nurses repeatedly expressed feelings of increasing frustration with addicted patients, negative emotional responses, and decreasing levels of job satisfaction as components of their compassion fatigue.

DISCUSSION

These emergency nurses identified 3 areas to improve their compassion: improved management support with encouragement across all work shifts, debriefing opportunities, and more education. Fostering a high level of self-awareness and understanding of how the work environment influences personal well-being are necessary strategies to avoid the frustrations and negative emotional responses associated with compassion fatigue.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review

BACKGROUND

No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley's instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale-Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress.

METHODS

A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological Abstracts Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle-Ottawa Scale.

RESULTS

Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review's findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores.

CONCLUSIONS

This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

The Effect on the Care Behaviors of Nurses Working in Intensive Care Clinics of Moral Distress Experienced During End of Life Patient Care

This research was conducted as a descriptive study in order to examine the effects of the moral problems experienced by nurses working in intensive care clinics on their end of life care behaviors. The data were collected using the Moral Distress Scale and Caring Behaviors Inventory. It was found that 74.5% of the nurses were women and their mean age was 32.60 ± 6.6 years. The frequency of moral distress in the nurses was 44.27 ± 16.25 and total score was 111.02 ± 63.85. There were significant differences in the scores of the concept the use of futile treatment by nurses, the decision not to begin life-support treatment being made only by physicians, and moral distress and discomfort felt by pediatric intensive care nurses (p < .05). A statistically significant relationship was found between total scores of discomfort on moral distress and assurance, knowledge and skills, connectedness, and being respectful on the end of life care behaviors (p < .05).

The Courage to Continue: Healthcare Social Worker's Resilience During COVID-19

The COVID-19 pandemic has exacerbated disparities in access to healthcare and mental health, often forcing healthcare social workers into ethical and moral dilemmas as they endeavor to provide equitable, humanistic care to their patients and caregivers. The purpose of this mixed method study was to explore how COVID-19-related personal and professional grief and losses impacted healthcare social worker's distress and resilience. Participants were recruited through healthcare social work professional organizations from September-November 2020. Participants (N = 246) completed an online survey capturing sociodemographic variables, as well as mental distress, pandemic-related meaning-making, and resilience. Data analysis included correlations and regressions pertaining to meaning-making, emotional distress, and resilience, as well as thematic analysis of participants' open-ended survey responses. Approximately one-third of participants reported emotional distress and difficulty in finding meaning from their pandemic-related losses. Participants reported a lower level of resilience when compared with the United States general population. Three themes emerged from social workers' qualitative responses: the hardest year of my career; the collective loss of our normal; and we were built for this. Pandemic-related grief permeates social workers' daily lives; yet their training and resilience foster hope to positively impact their clients, communities, and families.

How Supportive Ethical Relationships Are Negatively Related to Palliative Care Professionals' Negative Affectivity and Moral Distress: A Portuguese Sample

In the modern healthcare landscape, moral distress has become an increasingly common phenomenon among healthcare professionals. This condition is particularly prevalent among palliative care professionals who are confronted with bioethical issues in their daily practice. Although some studies described the effects of poor ethical climate and negative affectivity on moral distress, how these variables could be incorporated into a single model is still unclear. Thus, this study aims to investigate whether ethical relationships with the hospital could be related to the intensity and frequency of moral distress, both directly and as mediated by professionals' negative affectivity. Sixty-one Portuguese palliative care professionals completed web-based self-report questionnaires. After exploring descriptive statistics, mediation analyses were performed using the partial least squares method. The results indicated that the presence of positive relationships with the hospital reduced the professionals' negative affectivity levels. This, in turn, led palliative care professionals to experience a lower frequency and intensity of moral distress. Being a physician was positively associated with negative affectivity but not with the frequency of moral distress. Considering the protective role of ethical relationships with hospitals, health organizations could consider implementing interventions to improve hospitals' ethical climate and provide staff with ethics training programs.

Moral distress interventions: An integrative literature review

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Effective interventions for reducing moral distress in critical care nurses

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, as well as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses.

The Swedish translation and cultural adaptation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP)

BACKGROUND

Moral distress has been described as an emotionally draining condition caused by being prevented from providing care according to one's convictions. Studies have described the impact of moral distress on healthcare professionals, their situations and experiences. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) is a questionnaire that measures moral distress experienced by healthcare professionals at three levels: patient, system and team. The aim of this project was to translate and make a cultural adaption of the MMD -HP to the Swedish context.

METHODS

The questionnaire comprises 27 items, rated according to frequency and intensity on a five-point Likert scale (0-4). The procedure for translating MMD-HP followed WHO guidelines (2020). These entailed a forward translation from English to Swedish, a back translation, expert panel validation, pretesting and cognitive face-to-face interviews with 10 healthcare professionals from various professions and healthcare contexts.

RESULTS

The Swedish version of MMD-HP corresponds essentially to the concept of the original version. Parts of some items' had to be adjusted or removed in order to make the item relevant and comprehensible in a Swedish context. Overall, the cognitive interviewees recognized the content of the items which generally seemed relevant and comprehensible.

CONCLUSION

The Swedish version of MMD-HP could be a useful tool for measuring moral distress among healthcare professionals in a Swedish healthcare context.

Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic

BACKGROUND

Wide geographical variations in depression and anxiety rates related to the ethical climate have been reported during the COVID-19 pandemic in intensive care units (ICUs). The objective was to investigate whether moral distress is associated and has predictive values for depression, anxiety, and intention to resign.

METHODS

79 consenting ICU nurses completed MMD-HP and PHQ-4 scales in this cross-sectional study between October 2020-February 2021, after ethical approval. The association between MMD-HP and PHQ-4, and the predictive value of MMD-HP for anxiety, depression, and an intention to leave were analyzed (linear regression and receiver operating characteristics curve analysis).

RESULTS

From MMD-HP items, system related factors had highest scores (Kruskal-Wallis test, p < 0.0001). MMD-HP and PHQ-4 were weakly correlated (r = 0.41 [0.21-0.58]). MMD-HP and its system-related factors discriminate between nurses with and without depression or anxiety, while system-related factors differentiate those intending to resign (p < 0.05). The MMD-HP score had 50 [37.54-62.46] sensitivity with 80.95 [60-92.33] specificity to predict the intention to leave, and 76.12 [64.67-84.73] sensitivity with 58.33 [31.95-80.67] specificity to detect anxiety or depression symptoms.

CONCLUSIONS

During the COVID-19 pandemic, system-associated factors seem to be the most important root factors inducing moral distress. Moral distress is associated with negative psychological outcomes.

Spiritual Care as Part of an Interprofessional Model for Debriefing on an Oncology Unit

Health care clinicians who care for seriously ill and dying patients have been known to be at higher risk for burnout and moral distress. When not well supported in their workplace, clinicians may suffer additional adverse outcomes to their overall wellbeing. Self-care is one way to help mitigate these adverse outcomes. The literature has described formalized debriefing not only as a self-care strategy but an intervention to promote healthy team development. The focus of this paper will showcase how social work and spiritual care practitioners in our institution worked collaboratively to support an inpatient oncology unit to address issues related to burnout by providing staff with monthly debriefing sessions intended to enhance self-care and wellness in the workplace.

Clinician distress in seriously ill patient care: A dimensional analysis

BACKGROUND

Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention.

RESEARCH PURPOSE

The purpose of this article was to investigate the nature of clinician distress.

RESEARCH DESIGN

Qualitative inductive dimensional analysis.

PARTICIPANTS AND RESEARCH CONTEXT

After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis.

ETHICAL CONSIDERATIONS

This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis.

FINDINGS

A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event.

DISCUSSION

This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed.

CONCLUSION

For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.

Moral Distress Among Interdisciplinary Critical Care Team Members at a Comprehensive Cancer Center

BACKGROUND

Moral distress (MD) has been linked to health care professional burnout, intent to leave, and decreased quality of care.

OBJECTIVES

The aim of this study was to describe the perceptions of MD among critical care interdisciplinary team members and assess the association of MD with team member characteristics.

METHODS

A descriptive cross-sectional design was used with interdisciplinary team members in an intensive care unit setting at an NCI-designated Comprehensive Cancer Center in the southeastern United States. The Measure of Moral Distress for Healthcare Professionals was provided to registered nurses, oncology technicians, providers, respiratory therapists, and ancillary team members (social workers, pharmacists, dietitians).

RESULTS

A total of 67 team members completed the survey. Mean responses for 3 items were higher than 8 (halfway point of scale): "Follow family's insistence to continue aggressive treatment even though I believe it is not in the best interest of patient" (mean [SD], 11.4 [4.8]); "Continue to provide aggressive treatment for a patient most likely to die regardless of this treatment when no one will make a decision to withdraw it" (mean [SD], 10.5 [5.3]); and "Witness providers giving 'false hope' to patient/family" (mean [SD], 9.0 [5.3]). Higher responses on the "Continuing to provide aggressive treatment" item was associated with having "considered leaving due to MD" (P = .027) and "considering leaving now due to MD" (P = .016). Higher total scores were related to having left or considered leaving a job (P = .04). When examining education level, registered nurses with a master's degree (n = 5) exhibited the most MD (P = .04).

CONCLUSION

This study suggests that the Measure of Moral Distress for Healthcare Professionals is useful in identifying areas for focused efforts at reducing MD for interdisciplinary teams.

Beyond technology, drips, and machines: Moral distress in PICU nurses caring for end-of-life patients

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long-term consequences to the individual. Critical care areas are fraught with ethical issues, and end-of-life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality.

Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study

Background

The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19.

Methods

An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19.

Results

Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior.

Conclusion

Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00641-3.

Interventions to reduce moral distress in clinicians working in intensive care: A systematic review

OBJECTIVE

To evaluate the effectiveness of interventions to mitigate the harmful effects of moral distress experienced by nursing and medical clinicians working in the intensive care setting.

DESIGN

Eligible studies were identified from searches of PubMed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus. Included studies were published prior to 20 August 2020.

RESULTS

Twelve studies were included in this review comprising three randomised controlled trials, seven quasi-randomised trials and two observational studies. Nine studies reported interventions targeting only nurses while three included both nurses and doctors. The types of interventions identified included: moral empowerment programs, end-of-life educational programs, reflective exercises through individual narrative writing or group reflective debriefing, multidisciplinary case debriefing meetings integrated into clinical practice and moral resiliency training. Due to the overall low methodological quality and high risk of bias, no single intervention may be considered efficacious in managing moral distress.

CONCLUSIONS

There is weak evidence that some currently available interventions reduce the moral distress experienced by intensive care health care providers. Larger randomised trials involving all intensive healthcare clinicians are required to evaluate multifaceted interventions.

An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy

BACKGROUND

Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress.

OBJECTIVES

The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points.

METHODS

Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used.

RESULTS

At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly.

DISCUSSION

This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

Interventions to mitigate moral distress: A systematic review of the literature

BACKGROUND

Moral distress is a pervasive phenomenon that can negatively impact healthcare professionals and has been well studied in nursing populations. Much of the evidence suggests that it is associated with intention to leave high acuity areas and the profession. Despite the increasing amounts of research to explore the causes and effects of moral distress, there is limited research on interventions that mitigate the negative effects of moral distress.

OBJECTIVES

The aims of this systematic review were to: (a) identify and examine interventions developed to address moral distress experienced by health care professionals (b) examine the quality of the research methods and (c) report on the efficacy of these interventions.

DESIGN

We conducted a systematic review of interventional studies developed to mitigate moral distress.

DATA SOURCE

Medline, Embase, PsycINFO, CINAHL and Cochrane were searched for relevant studies (July 2019- September 2019). Additional bioethics databases and reference lists were also hand-searched.

REVIEW METHODS

The first author reviewed all retrieved titles and abstracts with a low tolerance for borderline papers based on inclusion and exclusion criteria, and those papers were reviewed and discussed by all authors to determine inclusion. Quality appraisal was conducted on the included studies using narrative synthesis to compare the findings. Data were extracted and compared by all authors and then reviewed by the first author for consistency.

RESULTS

Sixteen papers were included for full text review and the following interventions identified: educational interventions of varying length and breadth; facilitated discussions ranging from 30 to 60 minutes; specialist consultation services; an intervention bundle; multidisciplinary rounds; self-reflection and narrative writing. Researchers reported statistically significant reductions in moral distress using pre and post surveys, including one mixed methods program evaluation (n=7). The qualitative program evaluation provided participant quotations to suggest their program was beneficial. There were no statistically significant findings in the other studies (n=8). All studies had limitations in design and methodology presenting significant threats to validity.

CONCLUSION

Designing rigorous research studies that measure the impact of interventions aimed at mitigating moral distress continues to be challenging. The primary reason being that moral distress is a subjective ethical phenomenon with a number of different causes and effects. This calls for interventions that are flexible and sensitive to individual's needs. To build an evidence-base, interventions should also be measurable and research methods need to be scientifically rigorous. To achieve rigor and innovation, researchers should clearly justify their methodological choices. Tweetable abstract: Interventions to mitigate moral distress: a systematic review of the literature. Educational interventions offer a promising direction but more research is needed.

The Glasgow Coma Scale: A European and Global Perspective on Enhancing Practice

Although the Glasgow Coma Scale has made a positive contribution to the care of people with neurologic orders, variance exists in its understanding and application secondary to inconsistency in guidelines, their interpretation, and the educational approach to the use of the tool. This fragmentation has been evidenced to result in variances in practice, some potentially harmful. Also, recent evidence demonstrates human factors, such as distress, have not been addressed within such education and guidelines for use. An opportunity now exists to take a new, unified approach to education and standards for use of the tool, framed within a person-centered context.

'Death rounds to support critical care nurses: a qualitative study'

OBJECTIVE

Providing end-of-life care has a significant psychological impact on critical care nurses. Little is known about whether critical care nurses find death rounds useful as a support system. This study aimed to describe critical care nurses' perceptions of attending death rounds.

METHODS

This study was conducted using a qualitative descriptive design, using one-to-one audio-recorded interviews. The study was conducted at a 20-bed medical intensive care unit in a 1200-bed public tertiary hospital in Singapore. One-to-one interviews were conducted with 14 nurses using a semi-structured interview guide. Data was analysed using thematic analysis.

RESULTS

Critical care nurses valued attending death rounds. They found death rounds to be an outlet to express themselves and remember patients, to draw and give peer support, to build nursing and interprofessional cohesiveness and to learn to improve palliative care. The death rounds were optimal when they felt safe to share, when there was a good facilitator, when the hierarchy was flat and when the audience was interdisciplinary. The barriers to a successful death round were the rounds being too formal, timing and not knowing the patients.

CONCLUSION

Death rounds are a viable way to support critical care nurses in providing end-of-life care.

Death Cafés for prevention of burnout in intensive care unit employees: study protocol for a randomized controlled trial (STOPTHEBURN)

BACKGROUND

Burnout is an occupational syndrome that leads to mental health problems, job turnover, and patient safety events. Those caring for critically ill patients are especially susceptible due to high patient mortality, long hours, and regular encounters with trauma and ethical issues. Interventions to prevent burnout in this population are needed. Preliminary studies suggest debriefing sessions may reduce burnout. This study aims to assess whether participation in regular debriefing can prevent burnout in intensive care unit (ICU) clinicians.

METHODS

A randomized controlled trial will be conducted in two large academic medical centers. Two hundred ICU clinicians will be recruited with target enrollment of 100 physicians and 100 non-physicians (nurses, pharmacists, therapists). Participants must have worked in the ICU for the equivalent of at least 1 full time work week in the preceding 4 weeks. Enrolled subjects will be randomized to virtually attend biweekly debriefing sessions facilitated by a psychotherapist for 3 months or to a control arm without sessions. Our debriefs are modeled after Death Cafés, which are informal discussions focusing on death, dying, loss, grief, and illness. These sessions allow for reflection on distressing events and offer community and collaboration among hospital employees outside of work. The primary outcome is clinician burnout as measured by the Maslach Burnout Inventory (MBI) Score. Secondary outcomes include depression and anxiety, as measured by the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7-item scale (GAD-7), respectively. Questionnaires will be administered prior to the intervention, at 1 month, at 3 months, and at 6 months after enrollment. These values will be compared between groups temporally. Qualitative feedback will also be collected and analyzed.

DISCUSSION

With ICU clinician burnout rates exceeding 50%, Death Café debriefing sessions may prove to be an effective tool to avert this debilitating syndrome. With COVID-19 limiting social interactions and overloading ICUs worldwide, the virtual administration of the Death Café for ICU clinicians provides an innovative strategy to potentially mitigate burnout in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04347811 . Registered on 15 April 2020.