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Yi L, Chen Z, Jiménez-Herrera MF, Gan X, Ren Y, Tian X. The impact of moral resilience on nurse turnover intentions: the mediating role of job burnout in a cross-sectional study. BMC Nurs 2024; 23:687. [PMID: 39334202 PMCID: PMC11437732 DOI: 10.1186/s12912-024-02357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND High nursing staff turnover is a critical issue that negatively impacts the quality of care and patient safety. Turnover intentions, a key predictor of actual turnover, reflect an individual's likelihood of leaving their current position. Understanding the underlying mechanisms driving nurse turnover intentions is crucial for developing targeted interventions to stabilize the nursing workforce globally. OBJECTIVES This study aims to explore the relationship between moral resilience, job burnout, and turnover intentions among nurses, focusing on the mediating role of job burnout in this relationship. DESIGN This study employed a quantitative, cross-sectional design. METHODS A convenience sample of 322 registered nurses was recruited from two tertiary hospitals in China between August and October 2023. Data were collected using the Chinese version of the Rushton Moral Resilience Scale (Chi-RMRS), the Maslach Burnout Inventory (MBI), and the Turnover Intention Scale. Data analyses were conducted using SPSS 26.0 and Amos 21.0. The study followed the STROBE guidelines for observational research. ETHICAL CONSIDERATION Before the commencement of data collection, the Institutional Review Board of Hunan Traditional Chinese Medical College (YXLL202401004) granted ethical approval. RESULTS The proposed model exhibited an excellent fit to the data, with fit indices as follows: χ2/df = 1.819, CFI = 0.977, TLI = 0.961, RMSEA = 0.072 (90% confidence interval [CI]: 0.033 to 0.107). The structural equation model revealed that moral resilience was inversely associated with job burnout and turnover intentions. Furthermore, job burnout fully mediated the relationship between moral resilience and turnover intentions (β = -0.473, p = 0.007). Further analysis indicated that the depersonalization component of job burnout was the sole mediator in the relationship between moral resilience and turnover intention (β = -3.934, 95% CI [-5.837, -1.932]). CONCLUSION The findings indicate that moral resilience among nurses is negatively associated with turnover intentions, with this effect fully mediated by the depersonalization dimension of job burnout. Enhancing moral resilience in nurses may be valuable strategy for healthcare administrators to mitigate job burnout and subsequently reduce turnover intentions.
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Affiliation(s)
- Lijuan Yi
- Department of Nursing, Hunan Traditional Chinese Medical College, Zhuzhou, China
- Nursing Department, Universitat Rovira i Virgili, Tarragona, Spain
| | - Zhuomei Chen
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, Chongqing, China
| | | | - Xiuni Gan
- Department of Nursing, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Ren
- Chongqing Center for Evidence-based Traditional Chinese Medicine, Chongqing Traditional Chinese Medicine Hospital, No.6 of Panxi 7th Branch Road, Jiangbei District, Chongqing, 400030, China.
| | - Xu Tian
- Chongqing Center for Evidence-based Traditional Chinese Medicine, Chongqing Traditional Chinese Medicine Hospital, No.6 of Panxi 7th Branch Road, Jiangbei District, Chongqing, 400030, China.
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Rost M, Montagnoli C, Eichinger J. Causes of moral distress among midwives: A scoping review. Nurs Ethics 2024:9697330241281498. [PMID: 39331618 DOI: 10.1177/09697330241281498] [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: 09/29/2024]
Abstract
Numerous studies have evidenced moral distress among midwives; however, to date no research synthesis on causes of moral distress among midwives has been conducted. A scoping review was carried out to identify, comprehensively map, and categorize possible causes of moral distress among midwives, and to identify knowledge gaps. Six data bases were searched using Boolean logic. To be included, studies had to (a) present empirical findings on (b) causes of moral distress (c) among midwives (d) in English, German, French, or Italian. We included a final set of 43 studies. The vast majority of studies came from high-income countries (83.7%) and used a qualitative approach (69.8%); 48.8% of the studies were published in the past 5 years. Identified single reasons of moral distress were grouped into eight broader clusters, forming a coherent framework of reasons of moral distress: societal disregard, contemporary birth culture, resources, institutional characteristics, interprofessional relationships, interpersonal mistreatment of service users, defensive practice, and challenging care situations. These clusters mostly capture moral distress resulting from a conflict between external constraints and personal moral standards, with a smaller proportion also from an intraindividual conflict between multiple personal moral standards. Despite projected increases in demand for midwives, the midwifery workforce globally faces a crisis and is experiencing substantial strain. Moral distress further exacerbates the shortage of midwives, which negatively affects birth experiences and birth outcomes, ultimately rendering it a public health issue. Our findings offer points of leverage to better monitor and alleviate moral distress among midwives, contributing to reducing attrition rates and improving birth experiences and birth outcomes. Further research is essential to explore the issue of ecological moral distress, develop evidence-based interventions aimed at alleviating moral distress among midwives, and evaluate the effects of both individual and system-level interventions on midwives, intrapartum care, and service users' outcomes.
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Affiliation(s)
| | - Caterina Montagnoli
- University of Basel
- University of Applied Sciences and Arts of Western Switzerland
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Li F, Zhong J, He Z. Moral distress, moral resilience, and job embeddedness among pediatric nurses. Nurs Ethics 2024; 31:584-596. [PMID: 38128146 DOI: 10.1177/09697330231218347] [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
BACKGROUND Nurses often face ethical issues in their daily work that can have an impact on their level of job embeddedness. And positive job embeddedness is essential to reduce burnout among nurses and improve professional retention in the medical industry. However, few studies have focused on the relationship between moral distress, moral resilience, and job embeddedness. OBJECTIVES To investigate the relationship between moral distress, moral resilience, and job embeddedness, and explore the mediating role of moral resilience between moral distress and job embeddedness among nurses. DESIGN A quantitative, cross-sectional study. METHODS Nurses from a number of tertiary general hospitals in central China were surveyed and assessed using the Moral Distress Scale, the Nurse Moral Resilience Scale, and the nurse job embeddedness Scale from February to March 2023. The study was conducted in line with the 1964 Declaration of Helsinki. ETHICAL CONSIDERATION All study procedures were approved by the Ethics Committee of Hunan Normal University (No. 2023-313). FINDINGS Moral distress was positively correlated with moral resilience (β = 0.525, p < 0.01) and negatively correlated job embeddedness (β = -0.470, p < 0.01). Moral resilience partially mediated the relationship between moral distress with job embeddedness (β = -0.087, p < 0.01). DISCUSSION The findings reveal a relationship between moral distress, job embeddedness, and moral resilience among nurses. CONCLUSION Moral distress and moral resilience are important correlates of job embeddedness in nurses. Interventions to reduce moral distress and increase moral resilience may have potential benefits for improving nurses' job embeddedness. It is recommended that clinical nursing administrators create a favorable ethical atmosphere, educate nurses about ethics, and increase nurses' moral resilience.
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Affiliation(s)
| | | | - Ziyuan He
- Hunan Vocational College of Science and Technology
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Thomas TA, Kumar S, Davis FD, Boedeker P, Thammasitboon S. Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals. AJOB Empir Bioeth 2024; 15:120-132. [PMID: 38165288 DOI: 10.1080/23294515.2023.2297922] [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: 01/03/2024]
Abstract
OBJECTIVE Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress. DESIGN Cross-sectional survey. SETTING Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States. PARTICIPANTS Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study. MAIN OUTCOME MEASURES Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM). RESULTS Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82). CONCLUSIONS We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.
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Affiliation(s)
- Tessy A Thomas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Health System, Danville, PA, USA
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Shelley Kumar
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - F Daniel Davis
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Peter Boedeker
- Department of Education, Innovation and Technology, Baylor College of Medicine, Houston, TX, USA
| | - Satid Thammasitboon
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Carlson J. Organizational Virtue Ethics and Moral Distress among Healthcare Workers. THE JOURNAL OF CLINICAL ETHICS 2024; 35:169-179. [PMID: 39145575 DOI: 10.1086/730869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
AbstractMoral distress is traditionally defined as situations where one knows the right thing to do but external constraints make it nearly impossible to pursue the right course of action. Many interventions to mitigate moral distress focus on making healthcare workers more resilient or courageous in the face of adverse circumstances. While these "virtue cultivation" responses might be valuable traits for individuals, I want to argue that cultivating virtue is at best an incomplete strategy for dealing with moral distress in an organizational setting. The individualistic character of these approaches ignores how an organization's policies may be contributing to many morally distressing situations. I will argue that resources from the virtue tradition can still play a valuable theoretical role in addressing moral distress in healthcare settings if we transpose them to the organizational level. The policies of a hospital or healthcare institution can be seen as virtuous to the degree that they further the organization's goals of medicine. Organizational virtue ethics can then illuminate the issue of moral distress in healthcare organizations. If an organization's policies contribute to its members suffering from moral distress, then that policy may well inhibit the organization from carrying out its mission of providing excellent healthcare. Organizations should respond to moral distress and seek ways to mitigate if not eliminate it.
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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.
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Seidlein AH, Kuhn E. When nurses' vulnerability challenges their moral integrity: A discursive paper. J Adv Nurs 2023; 79:3727-3736. [PMID: 37232274 DOI: 10.1111/jan.15717] [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] [Received: 11/14/2022] [Revised: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Both vulnerability and integrity represent action-guiding concepts in nursing practice. However, they are primarily discussed regarding patients-not nurses-and considered independently from rather than in relation to each other. AIM The aim of this paper is to characterize the moral dimension of nurses' vulnerability and integrity, specify the concepts' relationship in nurses' clinical practice and, ultimately, allow a more fine-grained understanding. DESIGN This discursive paper demonstrates how vulnerability and integrity relate to each other in nursing practice and carves out which types of vulnerability pose a threat to nurses' moral integrity. The concept of vulnerability developed by Mackenzie et al. (2014) is applied to the situation of nurses and expanded to include the concept of moral integrity according to Hardingham (2004). Four scenarios are used to demonstrate where and how nurses' vulnerabilities become particularly apparent in clinical practice. This leads to a cross-case discussion, in which the vulnerabilities identified are examined against the background of moral integrity and the relationship between the two concepts is determined in more detail. RESULTS AND CONCLUSION Vulnerability and integrity do not only form a conceptual pair but also represent complementary moral concepts. Their joint consideration has both a theoretical and practical added value. It is shown that only specific forms of vulnerability pose a threat to moral integrity and the vulnerability-integrity relationship is mediated via moral distress. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The manuscript provides guidance on how the concrete threat(s) to integrity can be buffered and moral resilience can be promoted. Different types of threats also weigh differently and require specific approaches to assess and handle them at the micro-, meso- and macro-level of the healthcare system.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Eva Kuhn
- Section Global Health, Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
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Thomas TA, Davis FD, Thammasitboon S. Addressing wounded healers' burnout and moral distress: starts and ends with integrity. Int J Qual Health Care 2023; 35:mzad057. [PMID: 37440357 DOI: 10.1093/intqhc/mzad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Tessy A Thomas
- Department of Bioethics & Decision Sciences, Geisinger, 100 N. Academy Avenue, Danville, PA 17822, United States
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger, 100 N. Academy Avenue, Danville, PA 17822, United States
| | - Frank Daniel Davis
- Department of Bioethics & Decision Sciences, Geisinger, 100 N. Academy Avenue, Danville, PA 17822, United States
| | - Satid Thammasitboon
- Center for Research, Innovation and Scholarship in Medical Education, Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin Street, Suite A118, Houston, TX 77030, United States
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Rushton CH. Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice. Am J Crit Care 2023; 32:238-248. [PMID: 37391375 DOI: 10.4037/ajcc2023207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Ethical challenges are inherent in nursing practice. They affect patients, families, teams, organizations, and nurses themselves. These challenges arise when there are competing core values or commitments and diverse views on how to balance or reconcile them. When ethical conflict, confusion, or uncertainty cannot be resolved, moral suffering ensues. The consequences of moral suffering in its many forms undermine safe, high-quality patient care, erode teamwork, and undermine well-being and integrity. My experience as a nurse in the pediatric intensive care unit and later as a clinical nurse specialist in confronting these moral and ethical challenges has been the foundation of my program of research. Together we will explore the evolution of our understanding of moral suffering-its expressions, meanings, and consequences and attempts to measure it. Moral distress, the most described form of moral suffering, took hold within nursing and slowly within other disciplines. After 3 decades of research documenting the existence of moral distress, there were few solutions. It was at this juncture that my work pivoted toward exploring the concept of moral resilience as a means for transforming but not eliminating moral suffering. The evolution of the concept, its components, a scale to measure it, and research findings will be explored. Throughout this journey, the interplay of moral resilience and a culture of ethical practice were highlighted and examined. Moral resilience is continuing to evolve in its application and relevance. Many vital lessons have been learned that can inform future research and guide interventions to harness the inherent capabilities of clinicians to restore or preserve their integrity and to engage in large-scale system transformation.
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Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is the Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics, and a professor of nursing and pediatrics, Johns Hopkins University School of Nursing, Baltimore, Maryland
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Fischer-Grönlund C, Brännström M, Isaksson U. Psychometric testing of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP). BMC Med Ethics 2023; 24:35. [PMID: 37254086 DOI: 10.1186/s12910-023-00916-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/17/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Moral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one's values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP). METHODS Eighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach's alpha was calculated for each domain and for the scale as a whole. RESULTS The scale as a whole showed a Cronbach's alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ2/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912). CONCLUSIONS We found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.
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Affiliation(s)
| | - Margareta Brännström
- Department of Nursing, Umeå University, Campus Skellefteå, 93187, Skellefteå, Sweden
| | - Ulf Isaksson
- Department of Nursing, Umeå University, Linnaeus v 9, 90736, Umeå, Sweden
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Bergman ME, Gaskins VA, Allen T, Cheung HK, Hebl M, King EB, Sinclair RR, Siuta RL, Wolfe C, Zelin AI. The Dobbs Decision and the Future of Occupational Health in the US. OCCUPATIONAL HEALTH SCIENCE 2023; 7:1-37. [PMID: 36843836 PMCID: PMC9940085 DOI: 10.1007/s41542-023-00143-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 02/25/2023]
Abstract
Access to abortion care has a profound impact on women's ability to participate in the workforce. In the US, restrictions on abortion care have waxed and waned over the years, including periods when abortion was broadly permitted across the nation for most pregnant people for a substantial proportion of pregnancy and times when restrictions varied across states, including states where abortion is banned for nearly all reasons. Additionally, access to abortion care has always been a reproductive justice issue, with some people more able to access this care than others even when it is structurally available. In June 2022, the US Supreme Court handed down the Dobbs v. Jackson Women's Health Organization, returning to states the ability to determine restrictions on abortion, including near-total bans on abortion. In this anthology, ten experts share their perspectives on what the Dobbs decision means for the future, how it will exacerbate existing, well-researched issues, and likely also create new challenges needing investigation. Some contributions are focused on research directions, some focus on implications for organizations, and most include both. All contributions share relevant occupational health literature and describe the effects of the Dobbs decision in context.
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Gustavsson ME, Juth N, Von Schreeb J, Arnberg FK. Moral Stress among Swedish Health Care Workers During the COVID-19 Pandemic: A Cross-Sectional Study. SCANDINAVIAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 2023. [DOI: 10.16993/sjwop.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
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Gustavsson ME, Juth N, Arnberg FK, von Schreeb J. Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders. Confl Health 2022; 16:24. [PMID: 35527276 PMCID: PMC9079207 DOI: 10.1186/s13031-022-00456-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges. Methods Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis. Results We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate. Conclusion The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00456-y.
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Spilg EG, Rushton CH, Phillips JL, Kendzerska T, Saad M, Gifford W, Gautam M, Bhatla R, Edwards JD, Quilty L, Leveille C, Robillard R. The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic. BMC Psychiatry 2022; 22:19. [PMID: 34991514 PMCID: PMC8734541 DOI: 10.1186/s12888-021-03637-w] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/30/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs. METHODS A total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed. FINDINGS Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|]. INTERPRETATION Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.
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Affiliation(s)
- Edward G Spilg
- Department of Medicine, University of Ottawa and Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.
| | - Cynda Hylton Rushton
- Berman Institute of Bioethics & School of Nursing, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Jennifer L Phillips
- The University of Ottawa Institute of Mental Health Research at The Royal, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
- Faculty of Medicine, University of Ottawa, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
| | - Tetyana Kendzerska
- Department of Medicine, University of Ottawa and Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada
| | - Mysa Saad
- The University of Ottawa Institute of Mental Health Research at The Royal, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
- Faculty of Medicine, University of Ottawa, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
| | - Wendy Gifford
- Faculty of Health Sciences, School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Mamta Gautam
- Faculty of Medicine, University of Ottawa, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
| | - Rajiv Bhatla
- Royal Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
| | - Jodi D Edwards
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Room 101, Ottawa, Ontario, K1G 5Z3, Canada
| | - Lena Quilty
- Centre for Addiction and Mental Health, 1025 Queen Street, Toronto, Ontario, M6J 1H1, Canada
| | - Chloe Leveille
- The University of Ottawa Institute of Mental Health Research at The Royal, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
| | - Rebecca Robillard
- The University of Ottawa Institute of Mental Health Research at The Royal, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Ottawa, Ontario, K1N 6N5, Canada
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15
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Fischer-Grönlund C, Brännström M. The Swedish translation and cultural adaptation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP). BMC Med Ethics 2021; 22:151. [PMID: 34772400 PMCID: PMC8588668 DOI: 10.1186/s12910-021-00722-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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16
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Thomas TA, Davis FD, Kumar S, Thammasitboon S, Rushton CH. COVID-19 and Moral Distress: A Pediatric Critical Care Survey. Am J Crit Care 2021; 30:e80-e98. [PMID: 34409428 DOI: 10.4037/ajcc2021999] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Moral distress adversely affects the delivery of high-quality patient care and places health care professionals at risk for burnout, moral injury, and the loss of professional integrity. OBJECTIVES To investigate whether pediatric critical care professionals are experiencing moral distress during the COVID-19 pandemic and, if so, for what reasons. METHODS An exploratory survey of pediatric critical care professionals was conducted via the Pediatric Acute Lung Injury and Sepsis Investigators Network from April to May 2020. The survey was derived from a framework integrating contemporary literature on moral distress, moral resilience, and expert consensus. Integration of descriptive statistics for quantitative data and thematic analysis for qualitative data yielded mixed insights. RESULTS Overall, 85.8% of survey respondents reported moral distress. Nurses reported higher degrees of moral distress than other professional groups. Inducers of moral distress were related to challenges to professional integrity and lack of organizational support. Five themes were identified: (1) psychological safety, (2) expectations of leadership, (3) connectedness through a moral community, (4) professional identity challenges, and (5) professional versus social responsibility. Most respondents were confident in their ability to reason through ethical dilemmas (76.0%) and think clearly when confronting an ethical challenge even when pressured (78.9%). CONCLUSIONS During the COVID-19 pandemic, pediatric critical care professionals are experiencing moral distress due to various factors that challenge their professional integrity. Despite these challenges, they also exhibit attributes of moral resilience. Organizations have opportunities to cultivate a psychologically safe and healthy work environment to mitigate anticipatory, present, and lingering moral distress.
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Affiliation(s)
- Tessy A. Thomas
- Tessy A. Thomas is an assistant professor of pediatrics and bioethics, Geisinger Janet Weis Children’s Hospital, Geisinger Medical Center, Danville, Pennsylvania
| | - F. Daniel Davis
- F. Daniel Davis is a professor of bioethics, Geisinger Medical Center
| | - Shelley Kumar
- Shelley Kumar is an instructor of pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Satid Thammasitboon
- Satid Thammasitboon is an associate professor of pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Cynda H. Rushton
- Cynda H. Rushton is a professor of clinical ethics and nursing, Johns Hopkins University School of Nursing, Baltimore, Maryland
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17
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Onyebeke W, Iroku-Malize T, McCullough LB, Grünebaum A, Chervenak FA. A professional virtues-based ethical framework for medical missions. AJOG GLOBAL REPORTS 2021; 1:100017. [PMID: 36277456 PMCID: PMC9564020 DOI: 10.1016/j.xagr.2021.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND More than 1.6 million physicians participate in medical missions each year. This effort is part of a long history of volunteerism and service to those in need in the form of medical missions to low-income countries. The Children's Health International Medical Project of Seattle has provided the following 7 guiding principles of sustainable short-term international medical missions: "mission, collaboration, education, service, teamwork, sustainability, and evaluation." The role of professional virtues in grounding these principles and thus guiding medical missions is underappreciated. OBJECTIVE To provide a professional virtues-based ethical framework for medical missions, this article addressed the question, "How should physicians design and implement a medical mission in a professionally responsible way?" Reference is made to one of the authors' experiences as a point of reference. STUDY DESIGN The authors addressed the questions on how to design and implement a medical mission based on 5 professional virtues: compassion, integrity, humility, self-effacement, and self-sacrifice. A concise, historically based explanation of each virtue was provided, and the implications of the aforementioned principles for medical missions were identified. RESULTS Compassion motivates the mission and its team members, whereas integrity, humility, self-effacement, and self-sacrifice guide team members as they act on the professional virtue of compassion. CONCLUSION These 5 professional virtues can be used to provide a practical framework for the professionally responsible design and implementation of medical missions.
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Affiliation(s)
- William Onyebeke
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwelll Health, Hofstra University, Hempstead, NY
| | - Tochi Iroku-Malize
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwelll Health, Hofstra University, Hempstead, NY
| | - Laurence B. McCullough
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwelll Health, Hofstra University, Hempstead, NY
| | - Amos Grünebaum
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwelll Health, Hofstra University, Hempstead, NY
| | - Frank A. Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwelll Health, Hofstra University, Hempstead, NY
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18
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Rushton CH, Thomas TA, Antonsdottir IM, Nelson KE, Boyce D, Vioral A, Swavely D, Ley CD, Hanson GC. Moral Injury and Moral Resilience in Health Care Workers during COVID-19 Pandemic. J Palliat Med 2021; 25:712-719. [PMID: 34678091 PMCID: PMC9081047 DOI: 10.1089/jpm.2021.0076] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs. Objectives: The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it. Design: Web-based exploratory survey. Setting/Subjects: HCWs from a research network in the U.S. mid-Atlantic region. Measurements: Survey items included: our outcome, Moral Injury Symptoms Scale-Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI). Results: Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms (p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious affiliation, and having ≥20 years in their profession. MR was a moderator of the effect of years of experience on MI. Conclusions: HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.
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Affiliation(s)
- Cynda H Rushton
- Johns Hopkins University School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Tessy A Thomas
- Department of Pediatrics, Janet Weis Children's Hospital-Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Inga M Antonsdottir
- Johns Hopkins University School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Katie E Nelson
- Johns Hopkins University School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Danielle Boyce
- Johns Hopkins University School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Anna Vioral
- Department of Nursing, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - Deborah Swavely
- Department of Nursing, Tower Health-Reading Hospital, West Reading, Pennsylvania, USA
| | - Cathaleen D Ley
- Department of Nursing, Luminis Health-Anne Arundel Medical Center, Annapolis, Maryland, USA
| | - Ginger C Hanson
- Johns Hopkins University School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
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19
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Akram F. Moral injury and the COVID-19 pandemic: A philosophical viewpoint. ETHICS, MEDICINE, AND PUBLIC HEALTH 2021; 18:100661. [PMID: 33778145 PMCID: PMC7988441 DOI: 10.1016/j.jemep.2021.100661] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/17/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Much has changed in healthcare during the coronavirus disease (COVID)-19 pandemic. Medicine, a profession of traditional principles and virtues, has faced unprecedented challenges in the light of scarce and unequal distribution of ventilators, testing, and personal protective equipment. Healthcare workers have been- and are increasingly likely to be- forced into situations that require difficult decision making under life-and-death conditions. Concepts of "medical necessity" and "maximum benefit" challenge healthcare systems that already struggle to manage unequal treatment and access to services, giving rise to moral distress and moral injury on the front lines. METHODS This article focuses on moral injury in the context of coronavirus disease (COVID)-19 pandemic. I review recent literature to highlight the psychological impact of many morally-injurious events that have been reported during the COVID-19 pandemic. With the help of a clinical vignette, I point out how healthcare systems adopt many utilitarian policies in times of excessive healthcare burden. A viewpoint is offered that many morally injurious events happen when healthcare workers, traditionally practicing Kantian and virtue ethics, are forced to follow utilitarian policies of healthcare system. CONCLUSION One form of moral injury may arise from inherent conflicts between individual deontological moral judgments and organizational utilitarian moral judgments. More research is needed to validate the philosophical viewpoint as well as to explore whether increased awareness and education of key principles within moral philosophy can better equip healthcare workers in situations when public health takes precedence over individual health.
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Affiliation(s)
- F Akram
- Saint-Elizabeths Hospital/DC Department of Behavioral Health, Washington, DC, USA
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20
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Abstract
Summary: Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.
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21
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Delany C, Benhamu J, McDougall R, Ko D, Jones H, Mileshkin L, Largey G, Clinch A, Heynemann S. Supporting cancer care clinicians to 'hold' their patients during and beyond the COVID-19 pandemic: a role for reflective ethics discussions. Intern Med J 2021; 51:1143-1145. [PMID: 34278682 PMCID: PMC8447295 DOI: 10.1111/imj.15375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 04/14/2021] [Accepted: 05/12/2021] [Indexed: 01/19/2023]
Abstract
The COVID-19 pandemic has placed an overwhelming burden on healthcare delivery globally. This paper examines how COVID-19 has affected cancer care clinicians' capacity to deliver cancer care in the Australian context. We use the lens of 'holding patients' (drawing from attachment theory, psychology and from Australian Indigenous knowledge) to conceptualise cancer clinicians' processes of care and therapeutic relationships with patients. These notions of 'holding' resonate with the deep responsibility cancer care clinicians feel towards their patients. They enrich ethical language beyond duties to benefit, avoid harm, respect patients' autonomy and provide just treatment. We consider the disruptive effects of COVID-19 on care delivery and on clinicians themselves. We then show how models of clinical ethics and other similar reflective discussion approaches are a relevant support mechanism to assist clinicians to process and make sense of COVID-19's disruptions to their professional ethical role of holding patients during and beyond the pandemic.
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Affiliation(s)
- Clare Delany
- Department of Medical Education, Melbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
| | - Joanne Benhamu
- Cancer Clinical Trials UnitPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Rosalind McDougall
- Melbourne School of Population and Global HealthThe University of MelbourneMelbourneVictoriaAustralia
| | - Danielle Ko
- Palliative CareAustin HealthMelbourneVictoriaAustralia
| | - Hayley Jones
- McCabe Centre for Law & CancerMelbourneVictoriaAustralia
| | - Linda Mileshkin
- Cancer Clinical Trials UnitPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Geraldine Largey
- Southern Health Integrated Cancer ServicesMonash HealthMelbourneVictoriaAustralia
| | - Alex Clinch
- Cancer Clinical Trials UnitPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
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22
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Saeed F, Duberstein PR, Epstein RM, Lang VJ, Liebman SE. Frequency and Severity of Moral Distress in Nephrology Fellows: A National Survey. Am J Nephrol 2021; 52:487-495. [PMID: 34153971 PMCID: PMC10073901 DOI: 10.1159/000516575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one's values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. METHODS We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0-4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define "frequent" and "moderate-to-severe" moral distress. RESULTS The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. CONCLUSION A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Public Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Ronald M. Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Valerie J Lang
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Scott E. Liebman
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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23
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Antonsdottir I, Rushton CH, Nelson KE, Heinze KE, Swoboda SM, Hanson GC. Burnout and moral resilience in interdisciplinary healthcare professionals. J Clin Nurs 2021; 31:196-208. [PMID: 34145678 DOI: 10.1111/jocn.15896] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To examine demographic and work characteristics of interdisciplinary healthcare professionals associated with higher burnout and to examine whether the four domains of moral resilience contribute to burnout over and above work and demographic variables. BACKGROUND Healthcare professionals experience complex ethical challenges on a daily basis leading to burnout and moral distress. Measurement of moral resilience is a new and vital step in creating tailored interventions that will foster moral resilience at the bedside. DESIGN Cross-sectional descriptive design. METHODS Healthcare professionals in the eastern USA were recruited weekly via email for 3 weeks in this cross-sectional study. Online questionnaires were used to conduct the study. The STROBE checklist was used to report the results. RESULTS Work and demographic factors, such as religious preference, years worked in a healthcare profession, practice location, race, patient age, profession and education level, have unique relationships with burnout subscales and turnover intention, with the four subscales of moral resilience demonstrating a protective relationship with outcomes above and beyond the variance explained by work and demographic characteristics. CONCLUSIONS Higher moral resilience is related to lower burnout and turnover intentions, with multiple work demographic correlates allowing for potential areas of intervention to deal with an increase in morally distressing situations occurring at the bedside. Additionally, patterns of significant and non-significant relationships between the moral resilience subscales and burnout subscales indicate that these subscales represent unique constructs. RELEVANCE TO CLINICAL PRACTICE Understanding the everyday, pre-pandemic correlations of moral resilience and burnout among interdisciplinary clinicians allows us to see changes that may exist. Measuring and understanding moral resilience in healthcare professionals is vital for creating ways to build healthier, more sustainable clinical work environments and enhanced patient care delivery.
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Affiliation(s)
| | - Cynda Hylton Rushton
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.,Berman Institute of Bioethics, Baltimore, MD, USA
| | | | - Katherine E Heinze
- Florida Atlantic University Christine E. Lynn College of Nursing, Boca Raton, FL, USA
| | - Sandra M Swoboda
- Johns Hopkins University Schools of Medicine and Nursing, Baltimore, MD, USA
| | - Ginger C Hanson
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
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24
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Colgrove N. If You Love the Forest, then Do Not Kill the Trees: Health Care and a Place for the Particular. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021. [DOI: 10.1093/jmp/jhab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
There are numerous ways in which “the particular”—particular individuals (whether patients or physicians), particular ideologies, values, beliefs, and perspectives—are sometimes overlooked, ignored, or even driven out of the healthcare profession. In many such cases, this is bad for patients, practitioners, and the profession (or so I argue). Hence, we should seek to find a place for the particular in health care. Specific topics that I examine in this essay include distribution of health care based on the particular needs of patients, the importance of protecting physicians’ right to conscientious objection, the value in tolerating a plurality of moral and medical perspectives within the field, and more. Ultimately, as the imagery in the essay’s title suggests, I argue that if one cares about the “well-being” of the medical profession (generally), then one should seek to avoid destroying the many diverse and particular entities that constitute it.
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25
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Kherbache A, Mertens E, Denier Y. Moral distress in medicine: An ethical analysis. J Health Psychol 2021; 27:1971-1990. [PMID: 33938314 DOI: 10.1177/13591053211014586] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Moral distress is a negative emotional response that occurs when physicians know the morally correct action but are prevented from taking it because of internal or external constraints. Moral distress undermines a physician's ethical integrity, leading to anger, poor job satisfaction, reduced quality of care and burnout. Scarce literature exists on the ethical aspects of moral distress in medicine. We conducted an ethical analysis of moral distress as experienced by physicians and analysed it from the literature using two predominant ethical theories: principlism and care ethics. Finally, we consider the emergence of moral distress in medicine during the COVID-19 pandemic.
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26
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Ewuoso C, Hall S, Dierickx K. How do healthcare professionals respond to ethical challenges regarding information management? A review of empirical studies. Glob Bioeth 2021; 32:67-84. [PMID: 33897255 PMCID: PMC8023626 DOI: 10.1080/11287462.2021.1909820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim This study is a systematic review that aims to assess how healthcare professionals manage ethical challenges regarding information within the clinical context. Method and Materials We carried out searches in PubMed, Google Scholar and Embase, using two search strings; searches generated 665 hits. After screening, 47 articles relevant to the study aim were selected for review. Seven articles were identified through snowballing, and 18 others were included following a system update in PubMed, bringing the total number of articles reviewed to 72. We used a Q-sort technique for the analysis of identified articles. Findings This study reveals that healthcare professionals around the world generally employ (to varying degrees) four broad strategies to manage different types of challenges regarding information, which can be categorized as challenges related to confidentiality, communication, professional duty, and decision-making. The strategies employed for managing these challenges include resolution, consultation, stalling, and disclosure/concealment. Conclusion There are a variety of strategies which health professionals can adopt to address challenges regarding information management within the clinical context. This insight complements current efforts aimed at enhancing health professional-patient communication. Very few studies have researched the results of employing these various strategies. Future empirical studies are required to address this. Abbreviations CIOMS: Council of International Organization of Medical Sciences; WHO: World Health Organization; AMA: American Medical Association; WMA: World Medical Association; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis; ISCO: International Standard Classification of Occupations; ILO: International Labour Office; SPSS: The Statistical Package for the Social Sciences
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Affiliation(s)
| | - Susan Hall
- Center for Applied Ethics, Stellenbosch University, Western-Cape, South Africa
| | - Kris Dierickx
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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27
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Eijkholt M, Broekman M, Balak N, Mathiesen T. Three pitfalls of accountable healthcare rationing. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106943. [PMID: 33441304 DOI: 10.1136/medethics-2020-106943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/24/2020] [Accepted: 12/07/2020] [Indexed: 06/12/2023]
Abstract
A pandemic may cause a sudden imbalance between available medical resources and medical needs where fundamental care to a patient cannot be delivered. Inability to fulfil a professional commitment to deliver care as needed can lead to distress among caregivers and patients. This distress is sometimes alleviated through mechanisms that hide the facts that care is rationed and not all medical needs are met. We have identified three mechanisms that jeopardise accountable and optimal allocation of resources: (1) hidden value judgements that allow rationing under the disguise of triage or prioritisation, (2) disguised conflict of interest between societal and individual patient's needs and (3) concealed biases in the application of medical tools. Under these three pitfalls decisions of resource allocation and who gets treated are handled as medical decisions: normative decisions are concealed and perceived as falling with the realm of medical judgement. Value judgements and moral agency are hidden to offer a 'false sense of medical judgement', while in fact there are several ethical judgements and biases at stake. The three pitfalls entail hidden normative deliberation and are inappropriate for sustainable healthcare delivery and resource allocation. We believe it is necessary to maintain transparency in decision making under conditions of insufficient resources to maintain trust in professional care givers and secure fair treatment allocation. Recognition of the pitfalls, by applying our recommendations, may help to ensure transparent and accountable distribution of care and contribute to public acceptance of the ethics behind rationing.
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Affiliation(s)
- Marleen Eijkholt
- Unit Ethics and Health Care, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marike Broekman
- Department of neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Naci Balak
- Istanbul Medeniyet University, Istanbul, İstanbul, Turkey
| | - Tiit Mathiesen
- Department of Neurosurgery and Dept of Clinical Medicine, University of Copenhagen, Copenhagen University Hospital, Kobenhavn, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Stockholm, Sweden
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28
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[Moral distress in medical students and young professionals: research desiderata in the context of the COVID-19 pandemic]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1483-1490. [PMID: 33180160 PMCID: PMC7659897 DOI: 10.1007/s00103-020-03244-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
Hintergrund Die COVID-19-Pandemie stellt Menschen, die in der medizinischen Versorgung arbeiten, vor besondere Herausforderungen. Ein Teil der Medizinstudierenden und ärztlichen Berufseinsteigenden, die in dieser Zeit in Einrichtungen der Gesundheitsversorgung ihre Mitarbeit beginnen, wird mit außergewöhnlichen moralischen Herausforderungen konfrontiert. Einige verfügen noch nicht über ausreichend Bewältigungsmöglichkeiten, um adäquat mit diesen Herausforderungen umzugehen. Dies kann zu sogenanntem moralischen Stress (MoS; Englisch: „moral distress“, MoD) führen. Dauerhafte oder intensive Belastung durch MoS kann gravierende Folgen haben. Geeignete Unterstützungsangebote haben das Potenzial, den Umgang mit MoS zu verbessern. Ziel Der Beitrag hat das Ziel, einen Überblick über den Stand der Forschung zu MoS von Medizinstudierenden und ärztlichen Berufseinsteigenden zu geben, um Lehrende mit Aus- und Weiterbildungsverantwortung und Ärzt*innen in Leitungspositionen für die Problematik zu sensibilisieren. Hauptteil In diesem Beitrag werden das wissenschaftliche Konzept MoS, bekannte Auslöser sowie Präventions- und Interventionsmöglichkeiten vorgestellt. Dazu wird das Thema Bezug nehmend auf die Veränderungen in der Patientenversorgung im Kontext der COVID-19-Pandemie analysiert und es werden Forschungsdesiderate aufgezeigt. Fazit Der Beitrag verdeutlicht die Notwendigkeit eines deutschsprachigen, interdisziplinären Diskurses über MoS bei Medizinstudierenden und Berufseinsteigenden.
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Newham R. Morality, normativity and measuring moral distress. Nurs Philos 2020; 22:e12319. [PMID: 32790120 DOI: 10.1111/nup.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 11/30/2022]
Abstract
It is known that people have been getting distressed for a long-time and healthcare workers, like the military, seem to fit criteria for being at particular risk. Fairly recently a term of art, moral distress, has been added to types of distress at work, though not restricted to work, they can suffer. There are recognized scales that measure psychological distress such as the General Health Questionnaire and the Kessler scales but moral distress it is claimed is different warranting its own scale. This seems to be because of both the intensity and nature of moral problems encountered at work that is so powerful and so destructive of moral agency and integrity. This paper will focus on how, if at all, moral distress is different by examining the idea of moral normativity. Moral normativity is understood as roughly the sort of thing that all rational persons would endorse regardless of his interests, having an "automatic reason giving force" and is likely to also require an overriding force. Specifically, it will examine how this force of moral claims seems to be needed for moral distress to be so destructive of healthcare professional's moral agency and integrity. This is related to the idea of warrantedness of the reaction of distress. Even if morality had such a strong normativity, one can still ask is distress the correct or warranted reaction? It seems plausible that if distress is a correct response for it to be both moral and warranted it needs a strong account of moral normativity. The idea of a distinct form of distress as moral distress may be true in theory but is too contested both ontologically and epistemologically for a useful practice of measurement at present.
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Affiliation(s)
- Roger Newham
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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Abstract
AbstractIntroduction:Current research of moral distress is mainly derived from challenges within high-resource health care settings, and there is lack of clarity among the different definitions. Disaster responders are prone to a range of moral challenges during the work, which may give rise to moral distress. Further, organizations have considered increased drop-out rates and sick leaves among disaster responders as consequences of moral distress. Therefore, initiatives have been taken to address and understand the impacts of moral distress and its consequences for responders. Since there is unclarity among the different definitions, a first step is to understand the concept of moral distress and its interlinkages within the literature related to disaster responders.Hypothesis/Problem:To examine how disaster responders are affected by moral challenges, systematic knowledge is needed about the concepts related to moral distress. This paper aims to elucidate how the concept of moral distress in disaster response is defined and explained in the literature.Methods:The paper opted to systematically map the existing literature through the methods of a scoping review. The searches derived documents which were screened regarding specific inclusion criteria. The included 16 documents were analyzed and collated according to their definitions of moral distress or according to their descriptions of moral distress.Results:The paper provides clarity among the different concepts and definitions of moral distress within disaster response. Several concepts exist that describe the outcomes of morally challenging situations, centering on situations when individuals are prevented from acting in accordance with their moral values. Their specific differences suggest that to achieve greater clarity in future work, moral stress and moral distress should be distinguished.Conclusion:Based on the findings, a conceptual model of the development of moral distress was developed, which displays a manifestation of moral distress with the interplay between the responder and the context. The overview of the different concepts in this model can facilitate future research and be used to illuminate how the concepts are interrelated.
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Welborn A. Moral distress of nurses surrounding neonatal abstinence syndrome: Application of a theoretical framework. Nurs Forum 2019; 54:499-504. [PMID: 31246289 DOI: 10.1111/nuf.12362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
TOPIC Neonatal nurses who care for infants with symptoms of neonatal abstinence syndrome (NAS) may experience moral distress through conflicting professional ethics. The nurse may find it difficult to simultaneously exemplify beneficence and nonmaleficence. OBJECTIVE The purpose of this paper is to explore the moral distress of nurses in the context of infants experiencing symptoms of NAS and apply a new conceptual model to this phenomenon. Understanding how nurses navigate moral dilemmas may provide insight into strategies to better support them to address moral conflict. METHODS Moral distress was explored in the context of nurses who care for infants with symptoms of NAS. A literature review was completed, followed by the application of the model onto the derived themes. RESULTS The theoretical application resulted in a framework that exemplifies the experience of caring for infants with symptoms of NAS and their families described by many nurses within the literature. If moral distress is not resolved, negative outcomes may be experienced by the nurse, with additional negative outcomes experienced by the family. CONCLUSION This theoretical model provided insight into the experience of moral distress surrounding nursing care for infants with symptoms of NAS. Additional research is needed to investigate moral residue and moral resilience in this particular caregiving dynamic.
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Affiliation(s)
- Amber Welborn
- The University of North Carolina at Greensboro, Greensboro, North Carolina
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Affiliation(s)
- Natalie Pattison
- Senior Clinical Nursing Research Fellow/Trust lead for Patient Public Involvement in Research
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- Dovehouse DB3 Fulham Road SW36JJ, CCOT offices, Downs Rd, London SM25PT, UK
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Abstract
AIMS The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. BACKGROUND Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. DESIGN Systematic literature review and narrative synthesis (November 2015-March 2016). DATA SOURCES Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946-Present, PsycINFO® 1967-Present, CINAHL® Plus 1937-Present, EMBASE 1974-24 February 2016, British Nursing Index 1994-Present, Social Care Online, Social Policy and Practice Database (1890-Present), ERIC (EBSCO) 1966-Present and Education Abstracts. REVIEW METHODS Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. RESULTS In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. CONCLUSION We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.
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Affiliation(s)
- Georgina Morley
- Georgina Morley, Center for Ethics in
Medicine, School of Social and Community Medicine, University of Bristol,
Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
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Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med 2018; 32:2115-2122. [PMID: 30320478 PMCID: PMC6271308 DOI: 10.1111/jvim.15315] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/12/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Concerns about ethical conflicts, moral distress, and burnout in veterinary practice are steadily increasing. Root causes of these problems have not been rigorously identified. Little research has been done to evaluate the existence of moral distress in North American veterinarians or to explore its impact on career sustainability and poor well-being. HYPOTHESIS/OBJECTIVES Ethical conflict and resultant moral distress are common occurrences in contemporary veterinary practice and negatively impact daily practice life, but may not be identified or labeled by veterinarians as such. ANIMALS No animals were used in this study. METHODS Mixed methods sequential explanatory design; confidential and anonymous on-line sampling of 889 veterinarians in North America. RESULTS A majority of respondents reported feeling conflict over what care is appropriate to provide. Over 70% of respondents felt that the obstacles they faced that prevented them from providing appropriate care caused them or their staff moderate to severe distress. Seventy-nine percent of participants report being asked to provide care that they consider futile. More than 70% of participants reported no training in conflict resolution or self-care. CONCLUSIONS AND CLINICAL IMPORTANCE Veterinarians report widespread ethical conflict and moral distress across many practice types and demographics. Most veterinarians have little to no training on how to decrease the impact of these problems. Ethical conflict and resulting moral distress may be an important source of stress and poor well-being that is not widely recognized or well defined. Well-researched and effective tools used to decrease moral distress in human healthcare could be adapted to ameliorate this problem.
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Key Words
- burnout: professional, negotiating, self-care, mental health, morals, surveys and questionnaires, medical futility, suicidal ideation, compassion fatigue, dissent and disputes
- stress: psychological, morals, suicide, ethical theory, ethical dilemma, empathy
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Affiliation(s)
- Lisa Moses
- MSPCA‐Angell Animal Medical CenterBostonMassachusetts
- Center for BioethicsHarvard Medical SchoolBostonMassachusetts
- Bioethics Center Scholar, Yale Interdisciplinary Center for BioethicsNew HavenConnecticut
| | | | - Jon Wesley Boyd
- Center for BioethicsHarvard Medical SchoolBostonMassachusetts
- Cambridge Health Alliance/Harvard Medical School, Department of Psychiatry, Center for Bioethics, Harvard Medical SchoolCambridgeMassachusetts
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Applying a Balm: Medicating the Patient to Treat the (Moral) Distress of Caregivers. J Hosp Palliat Nurs 2018; 20:433-439. [PMID: 30188434 DOI: 10.1097/njh.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.
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Rushton CH. Moral Resilience: A Capacity for Navigating Moral Distress in Critical Care. AACN Adv Crit Care 2017; 27:111-9. [PMID: 26909461 DOI: 10.4037/aacnacc2016275] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing and Pediatrics, Berman Institute of Bioethics, Johns Hopkins University School of Nursing, and Johns Hopkins University School of Medicine, 1809 Ashland Avenue, Baltimore, MD 21205
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Abstract
: Moral distress is a pervasive problem in the nursing profession. An inability to act in alignment with one's moral values is detrimental not only to the nurse's well-being but also to patient care and clinical practice as a whole. Moral distress has typically been seen as characterized by powerlessness and victimization; we offer an alternate view. Ethically complex situations and experiences of moral distress can become opportunities for growth, empowerment, and increased moral resilience. This article outlines the concept and prevalence of moral distress, describes its impact and precipitating factors, and discusses promising practices and interventions.
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Ponce Martinez C, Suratt CE, Chen DT. Cases That Haunt Us: The Rashomon Effect and Moral Distress on the Consult Service. PSYCHOSOMATICS 2017; 58:191-196. [DOI: 10.1016/j.psym.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 10/21/2022]
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Epstein EG, Hurst AR. Looking at the Positive Side of Moral Distress: Why It’s a Problem. THE JOURNAL OF CLINICAL ETHICS 2017. [DOI: 10.1086/jce2017281037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Winslade WJ. Moral Distress: Conscious and Unconscious Feelings. THE JOURNAL OF CLINICAL ETHICS 2017. [DOI: 10.1086/jce2017281042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Thomas TA, McCullough LB. Focus More on Causes and Less on Symptoms of Moral Distress. THE JOURNAL OF CLINICAL ETHICS 2017. [DOI: 10.1086/jce2017281030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Epstein EG, Hurst AR, Mahanes D, Marshall MF, Hamric AB. Is Broader Better? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:15-17. [PMID: 27901420 DOI: 10.1080/15265161.2016.1242669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Thomas TA, Bruce CR. Moral Distress: Professional Integrity as the Basis for Taxonomies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:11-13. [PMID: 27901437 DOI: 10.1080/15265161.2016.1239785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Campbell SM, Ulrich CM, Grady C. Response to Open Peer Commentaries on "A Broader Understanding of Moral Distress". THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:W1-W3. [PMID: 27901446 DOI: 10.1080/15265161.2016.1248579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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A Qualitative Study Exploring Moral Distress Among Pediatric Resuscitation Team Clinicians: Challenges to Professional Integrity. Pediatr Crit Care Med 2016; 17:e303-8. [PMID: 27182784 DOI: 10.1097/pcc.0000000000000773] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Our study objectives were to explore moral distress among pediatric team clinicians within the context of resuscitation experiences, and determine whether there were any distinctively ethical perspectives on moral distress that could be conceptualized as challenges to professional integrity, rather than to previously described psychological responses of clinicians. DESIGN Descriptive, exploratory qualitative study. SETTING A large tertiary pediatric academic hospital in Houston, TX. SUBJECTS Twenty-five PICU resuscitation team clinicians were interviewed from December 2012 to April 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All clinicians reported experiencing moral distress during certain resuscitations. Twenty-one of 25 clinicians reflected and acknowledged that their sense of professional integrity had been challenged during those resuscitation events. Four main components of resuscitation experience that induced moral distress were identified: 1) experiences where there was lack of understanding of the big picture; 2) experiences where there was suboptimal team leadership; 3) experiences where there was variable meanings to the word "resuscitation"; and 4) experiences were there was uncertainty of role responsibility. CONCLUSIONS The perception of moral distress exists among pediatric clinicians during resuscitations and could be conceptualized as challenges to professional integrity. This ethical framework offers an alternative approach to understanding and investigating the complex layers of moral distress.
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Carbajal MM. Considering a Balanced Approach to "Training Doctors for Person-Centered Care". ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:897-898. [PMID: 27351816 DOI: 10.1097/acm.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Melissa M Carbajal
- Assistant professor and director, Neonatal-Perinatal Fellowship Program, Department of Pediatrics, Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas;
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Dudzinski DM. Navigating moral distress using the moral distress map. JOURNAL OF MEDICAL ETHICS 2016; 42:321-324. [PMID: 26969723 DOI: 10.1136/medethics-2015-103156] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/20/2016] [Indexed: 06/05/2023]
Abstract
The plethora of literature on moral distress has substantiated and refined the concept, provided data about clinicians' (especially nurses') experiences, and offered advice for coping. Fewer scholars have explored what makes moral distress moral If we acknowledge that patient care can be distressing in the best of ethical circumstances, then differentiating distress and moral distress may refine the array of actions that are likely to ameliorate it. This article builds upon scholarship exploring the normative and conceptual dimensions of moral distress and introduces a new tool to map moral distress from emotional source to corrective actions. The Moral Distress Map has proven useful in clinical teaching and ethics-related debriefings.
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Clinical decision making in dementia: mapping the minefields. Br J Gen Pract 2015. [DOI: 10.3399/bjgp15x685981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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McCullough LB. Medicine as a Profession: A Hypothetical Imperative in Clinical Ethics. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2015; 40:1-7. [DOI: 10.1093/jmp/jhu047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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