Moral distress: an emerging problem for nurses in long‐term care?

Nursing students' experience of moral distress in clinical settings: A phenomenological study

AIM

To explore nursing students' moral distress (MD) experiences in clinical settings.

DESIGN

An interpretative phenomenological analysis (IPA) design was employed.

METHODS

Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method.

RESULTS

Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity.

CONCLUSION

Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Development and Evaluation of a Nurse Practitioner Huddles Toolkit for Long Term Care Homes

Long-term care homes (LTCHs) were disproportionately affected by the coronavirus disease (COVID-19) pandemic, creating stressful circumstances for LTCH employees, residents, and their care partners. Team huddles may improve staff outcomes and enable a supportive climate. Nurse practitioners (NPs) have a multifaceted role in LTCHs, including facilitating implementation of new practices. Informed by a community-based participatory approach to research, this mixed-methods study aimed to develop and evaluate a toolkit for implementing NP-led huddles in an LTCH. The toolkit consists of two sections. Section one describes the huddles' purpose and implementation strategies. Section two contains six scripts to guide huddle discussions. Acceptability of the intervention was evaluated using a quantitative measure (Treatment Acceptability Questionnaire) and through qualitative interviews with huddle participants. Descriptive statistics and manifest content analysis were used to analyse quantitative and qualitative data. The project team rated the toolkit as acceptable. Qualitative findings provided evidence on design quality, limitations, and recommendations for future huddles.

An Intersectional Analysis of Moral Distress and Intention to Leave Employment Among Long-Term Care Providers in British Columbia

Objectives: In this study, we aimed to explore the relationship between intersectional inequities and moral distress among those working in Long-Term Care (LTC) in British Columbia, Canada. Methods: This was a cross-sectional and retrospective study. We assessed moral distress, of 1678 respondents, using a modified Moral Distress Scale, and an equivalent distress mitigation score, at the intersections of gender and racial/ethnic identity. Then, we explored which worker attributes were more predictive of intention to leave work. Results: We found notable difference in experiences of moral distress across intersecting identities, including high moral distress scores among Indigenous men and women, and white women. Significant differences in mitigation scores were also found by intersectional identities. Discussion: Moral distress was the most important predictor of intention to leave work. The differences across racial and gender identity groups suggest the need for tailored interventions to address moral distress among LTC providers.

Nurse practitioner led implementation of huddles for staff in long term care homes during the COVID-19 pandemic

BACKGROUND

Staff working in long-term care (LTC) homes during COVID-19 frequently reported a lack of communication, collaboration, and teamwork, all of which are associated with staff dissatisfaction, health concerns, lack of support and moral distress. Our study introduced regular huddles to support LTC staff during COVID-19, led by a Nurse Practitioner (NP). The objectives were to evaluate the process of huddle implementation and to examine differences in outcomes between categories of staff (direct care staff, allied care and support staff, and management) who attended huddles and those who did not.

METHODS

All staff and management at one LTC home (< 150 beds) in Ontario, Canada were included in this pre-experimental design study. The process evaluation used a huddle observation tool and focused on the dose (duration, frequency) and fidelity (NP's adherence to the huddle guide) of implementation. The staff attending and non-attending huddles were compared on outcomes measured at post-test: job satisfaction, physical and mental health, perception of support received, and levels of moral distress. The outcomes were assessed with validated measures and compared between categories of staff using Bayesian models.

RESULTS

A total of 42 staff enrolled in the study (20 attending and 22 non-attending huddles). Forty-eight huddles were implemented by the NP over 15 weeks and lasted 15 min on average. Huddles were most commonly attended by direct care staff, followed by allied care/support, and management staff. All huddles adhered to the huddle guide as designed by the research team. Topics most often addressed during the huddles were related to resident care (46%) and staff well-being (34%). Differences were found between staff attending and non-attending huddles: direct care staff attending huddles reported lower levels of overall moral distress, and allied care and support staff attending huddles perceived higher levels of support from the NP.

CONCLUSIONS

NP-led huddles in LTC homes may positively influence staff outcomes. The process evaluation provided some understanding of why the huddles may have been beneficial: the NP addressed resident care issues which were important to staff, encouraged a collaborative approach to solving issues on the unit, and discussed their well-being.

TRIAL REGISTRATION NUMBER

NCT05387213, registered on 24/05/2022.

Moral distress in long-term care questionnaire modification and psychometric evaluation

BACKGROUND

Licensed nurses working in long-term care facilities experience ethical challenges if not resolved can lead to moral distress. There is a lack of an English-language validated tool to adequately measure moral distress in the long-term care setting.

AIMS

To describe the modification and psychometric evaluation of the Moral Distress Questionnaire.

METHODS

Instrument development and psychometric evaluation. Internal consistency using Cronbach's α to establish reliability was conducted using SPSS version 27.0 while SPSS Amos version 27.0 was used to perform a confirmatory factor analysis of the Moral Distress Questionnaire.

PARTICIPANTS

A national sample of US-licensed nurses who provided direct resident care in long-term care settings were recruited via a targeted sampling method using Facebook from 7 December 2020 to 7 March 2021.

ETHICAL CONSIDERATION

The study was approved by the university's human research protection program. Informed consent was provided to all participants.

RESULTS

A total of 215 participants completed the surveys. Confirmatory analysis indicated that the 21-item scale with a 4-factor structure for the Moral Distress Questionnaire model met the established criteria and demonstrates an acceptable model fit (CMIN/DF = 2.0, CFI = 0.82, TLI = 0.77, RMSEA = 0.07). Factor loadings for each item depict a moderate to a strong relationship (range 0.36-0.70) with the given underlying construct. Cronbach's α coefficient was 0.87 for the overall scale and 0.60-0.74 for its subscales which demonstrate good reliabilities.

DISCUSSION

This is the first English-language validated tool to adequately measure moral distress in the long-term care setting experienced by US long-term care nurses. This reliable and well-validated tool will help identify moral distress situations experienced by US long-term care nurses.

CONCLUSION

The modified 21-item English version of the Moral Distress Questionnaire is reliable tool that demonstrates good psychometric properties to validly measure sources of moral distress among direct resident care nurses.

Exploring the experiences of nurses' moral distress in long-term care of older adults: a phenomenological study

Background

Moral distress is a poorly defined and frequently misunderstood phenomenon, and little is known about its triggering factors during ICU end-of-life decisions for nurses in Iran. This study aimed to explore the experiences of nurses’ moral distress in the long-term care of older adults via a phenomenological study.

Methods

A qualitative, phenomenological study was conducted with 9 participants using in-depth semi-structured interviews. The purpose was to gain insight into the lived experiences and perceptions of moral distress among ICU nurses in hospitals affiliated with Tehran University of Medical Sciences during their long-term care of older adults.

Results

Five major themes are identified from the interviews: advocating, defense mechanisms, burden of care, relationships, and organizational issues. In addition, several subthemes emerged including respectful end of life care, symptom management, coping, spirituality, futile care, emotional work, powerlessness, relationships between patients and families, relationships with healthcare teams, relationships with institutions, inadequate staffing, inadequate training, preparedness, education/mentoring, workload, and support.

Conclusions

This qualitative study contributes to the limited knowledge and understanding of the challenges nurses face in the ICU. It also offers possible implications for implementing supportive interventions.

An effective in-hospital chaplaincy-led care program for nurses: Tea for the soul a qualitative investigation

Tea for the Soul (TFS) is an understudied care model, addressing bereavement and other emotional needs of nurses related to impactful patient care experiences. Nurses are at high risk for compassion fatigue, moral distress, and burnout. Facilitated by a Chaplain, the TFS program provides participants a venue to express their feelings and explore ways of adapting effectively with the death of a patient, and other traumatic workplace experiences. In this qualitative grounded theory study, hospital nurses (N = 7) who participated in TFS were interviewed. IRB approval was obtained. Questions were constructed within the context of the medical center research council and asked if TFS: (a) was personally beneficial, (b) helped nurses feel better about their work, and (c) affected job satisfaction. Four core themes emerged: (a) Nurses' Self-Care, (b) Professional Practice, (c) Community, and (d) Improved Patient Care Outcomes. The Roy Adaptation Model, Group Identity Mode was applied to the content analysis. Overarching themes were Compassionate Service, Ministry of Presence, Reflective Practice, and Sacred Encounters. Nurses reported that TFS facilitated a spiritual respite and a sense of enhanced community and was a source of strength and coping, thus may aid in the promotion of nurse well-being and the amelioration of moral distress, compassion fatigue, and burnout.

Application of the Roy Adaptation Theory to a care program for nurses

Theory-guided nursing practice is foundational in providing the framework for the development of excellent nursing care. There is a need for effective care programs for nurses, whereby they are adequately supported within their workplace infrastructures as a professional group whose work is essential to the provision of healthcare worldwide. Likewise, there is a need for care programs for nurses to be theory-guided. In the current global pandemic climate, the well-being of nurses continues to become compromised evidenced by increasing moral distress, compassion fatigue, and burnout. Theory-based supportive programs are vital to the overall wellbeing, morale, and retention of nurses. The Roy Adaptation Theory may serve as a guide in the development and evaluation of a hospital-based program designed to support the needs of the healthcare team. This discussion will explore the application of the Roy Adaptation Theory-Group Identity Mode to the Tea for the Soul Care Model for nurses.

Clima ético, estrés de conciencia y laboral de enfermeras y médicos que laboran en cuidados intensivos neonatal

El objetivo del presente estudio fue determinar la relación entre la percepción del clima ético, el estrés moral y el relacionado con el trabajo. El diseño fue descriptivo correlacional y el muestreo fue tipo censo con un total de muestra de 106 participantes (80 profesionales de enfermería y 26 médicos). Los resultados mostraron que existe una relación negativa y significativa del clima ético con el estrés laboral (rs =-.326, p<.01). Además, se identificó como hallazgo adicional que el clima ético predice el estrés relacionado con el trabajo, tanto en médicos como en enfermeras (R2=7.9, p=.004). La evidencia científica del presente estudio confirma que la bioética como ciencia debe ser competencia de todos los profesionales de la salud y, en particular, de la enfermería, debido a los desafíos éticos y morales de su práctica profesional, especialmente en áreas críticas debido a las políticas, la normatividad y los recursos con los que cuentan el lugar de trabajo. Tanto el clima ético como el estrés moral y laboral deben ser considerados por las instituciones de salud, teniendo en cuenta que pueden influir negativamente en la salud de los médicos y enfermeras que brindan los cuidados, lo cual limita la calidad de la atención.

Predict Moral Distress Using Workplace Stress, Stress of Conscience Mediated by Coping Using Roy Adaptation Model: A Path Analysis

BACKGROUND

Moral distress can be predisposed when nurses are exposed to ambiguous moral situations.

PURPOSE

Is to test a conceptual model based on Roy adaptation model (RAM) to examine the relationship among workplace stress, conscience stress, and moral distress mediated by coping.

DESIGN

A correlational, cross sectional.

RESULTS

Data were collected from 199 licensed nurses. The findings indicated that workplace stress was related negatively to coping processes (β = -.12) and that stress of conscience was predictive of greater use of coping process (β = -.21).

CONCLUSION

The results indicated that the model suggested based on RAM is saturated and is the perfect fit. However, the alternative models indicated that workplace stress moderately predicted moral distress.

Experiences of moral distress by privately hired companions in Ontario's long-term care facilities

Purpose

To explore long-term residential care provided by people other than the facilities' employees. Privately hired paid "companions" are effectively invisible in health services research and policy. This research was designed to address this significant gap. There is growing recognition that nursing staff in long-term care (LTC) residential facilities experience moral distress - a phenomenon in which one knows the ethically right action to take, but is systemically constrained from taking it. To date, there has been no discussion of the distressing experiences of companions in LTC facilities. This paper explores companions' moral distress.

Design

Data was collected using weeklong rapid ethnographies in seven LTC facilities in Southern Ontario, Canada. A feminist political economy analytic framework was used in the research design and in the analysis of findings.

Findings

Despite the differences in their work tasks and employment conditions, structural barriers can cause moral distress for companions. This mirrors the impacts experienced by nurses that are highlighted in the literature. Though companions are hired in order to fill care gaps in the LTC system, they too struggle with the current system's limitations. The hiring of private companions is not a sustainable or equitable solution to under-staffing and under-funding in Canada's LTC facilities.

Value

Recognizing moral distress and the impact that it has on those providing LTC is critical in terms of supporting and protecting vulnerable and precarious care workers and ensuring high quality care for Canadians in LTC.

Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students

Background:

Moral distress, moral sensitivity, and moral courage among healthcare professionals have been explored considerably in recent years. However, there is a paucity of studies exploring these topics among baccalaureate nursing students.

Aim/objective:

The purpose of this study was to explore the relationship between and among moral distress, moral sensitivity, and moral courage of undergraduate baccalaureate nursing students.

Research design:

The research employed a descriptive-correlational design to explore the relationships between and among moral distress, moral sensitivity, and moral courage of undergraduate nursing students.

Participants and research context:

A total of 293 baccalaureate Filipino nursing students who have been exposed to various clinical areas participated in the study.

Ethical considerations:

Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.

Findings:

Results indicate that a majority of the nursing students in the clinical areas encounter morally distressing situations that compromise quality patient care. However, despite the fact that they want to do what is in the best interest of their patients, their perception of being the inexperienced among the healthcare team drives the majority of them to ignore morally distressing situations to avoid conflict and confrontation. Another interesting finding is that 79.20% of the respondents hardly consider quitting the nursing profession even if they frequently encounter morally distressing situations. Analysis also shows associations between moral distress intensity and frequency ( r = 0.13, p < 0.05) and moral distress intensity and moral sensitivity ( r = 0.25, p < 0.05). The dimensions of moral courage are also related to both moral distress and moral sensitivity.

Conclusion:

Results of the study imply that moral distress is a reality among all healthcare professionals including nursing students and requires more consideration by nurse educators.

Spiritual well-being and moral distress among Iranian nurses

BACKGROUND

Moral distress is increasingly recognized as a problem affecting healthcare professionals, especially nurses. If not addressed, it may create job dissatisfaction, withdrawal from the moral dimensions of patient care, or even encourage one to leave the profession. Spiritual well-being is a concept which is considered when dealing with problems and stress relating to a variety of issues.

OBJECTIVE

This research aimed to examine the relationship between spiritual well-being and moral distress among a sample of Iranian nurses and also to study the determinant factors of moral distress and spiritual well-being in nurses.

RESEARCH DESIGN

A cross-sectional, correlational design was employed to collect data from 193 nurses using the Spiritual Well-Being Scale and the Moral Distress Scale-Revised.

ETHICAL CONSIDERATIONS

This study was approved by the Regional Committee of Medical Research Ethics. The ethical principles of voluntary participation, anonymity, and confidentiality were considered.

FINDINGS

Mean scores of spiritual well-being and moral distress were 94.73 ± 15.89 and 109.56 ± 58.70, respectively. There was no significant correlation between spiritual well-being and moral distress (r = -.053, p = .462). Marital status and job satisfaction were found to be independent predictors of spiritual well-being. However, gender and educational levels were found to be independent predictors for moral distress. Age, working in rotation shifts, and a tendency to leave the current job also became significant after adjusting other factors for moral distress.

DISCUSSION AND CONCLUSION

This study could not support the relationship between spiritual well-being and moral distress. However, the results showed that moral distress is related to many elements including individual ideals and differences as well as organizational factors. Informing nurses about moral distress and its consequences, establishing periodic consultations, and making some organizational arrangement may play an important role in the identification and management of moral distress and spiritual well-being.

Micro-citizenship, dementia and long-term care

In recent years there has been an increasing interest in the concept of citizenship as a lens through which to understand dementia practice. This move from an individualist, personhood-based approach towards an understanding of people with dementia as a group facing social and structural discrimination parallels, in some ways, that previously seen in the realms of disability and mental health which have sought to politicize those experiences. In so doing, the debate has sought to reconfigure power relations, insisting that members of such discriminated groups are people with power entitled to the same from life as everyone else. Much of the discussion to date has, understandably, focused on the larger issues of social inclusion, rights and responsibilities – reflecting the traditional concern of citizenship of individuals’ relationship to the state or the society in which they live. More recently, there has been a move to conceptualising citizenship as a practice – something that is realised through action and in relationship – rather than a status bestowed. In this paper, we seek to contribute to the discussion by introducing the concepts of midi- and micro-citizenship, taken from organisation studies, as a further means by which to link the personal and the political, and as grounds to build citizenship-alliances between people with dementia living in long-term care (LTC) facilities and front-line dementia care staff. We will then seek to illustrate the usefulness of these concepts in understanding citizenship in practice in LTC facilities through analysis of data drawn from focus groups involving LTC staff, and interviews with family carers whose relatives live in LTC facilities. In conclusion, we will explore some of the possibilities that such an approach holds for dementia care practice.

An exploration of emotional protection and regulation in nurse-patient interactions: The role of the professional face and the emotional mirror

INTRODUCTION

While interpersonal styles of nurse-patient communication have become more relaxed in recent years, nurses remain challenged in emotional engagement with patients and other health professionals. In order to preserve a professional distance in patient care delivery however slight, nurses need to be able to regulate their emotions.

AIM

This research aimed to investigate nurses' perceptions of emotional protection and regulation in patient care delivery.

METHODS

A qualitative approach was used for the study utilising in-depth semi-structured interviews and researcher reflective journaling. Participants were drawn from rural New South Wales. Following institutional ethics approval 5 nurses were interviewed and reflective journaling commenced. The interviews and the reflective journal were transcribed verbatim.

RESULTS

The results revealed that nurses' emotional regulation demonstrated by a 'professional face' was an important strategy to enable delivery of quality care even though it resulted in emotional containment. Such regulation was a protective mechanism employed to look after self and was critical in situations of emotional dissonance. The results also found that nurses experience emotional dissonance in situations where they have unresolved personal emotional issues and the latter was a individual motivator to manage emotions in the workplace.

CONCLUSION

Emotions play a pivotal role within nurse-patient relationships. The professional face can be recognised as contributing to emotional health and therefore maintaining the emotional health of nurses in practice. This study foregrounds the importance of regulating emotions and nurturing nurses' emotional health in contemporary practice.

Sources of moral distress for nursing staff providing care to residents with dementia

The World Health Organization estimates the number of people living with dementia at approximately 35.6 million; they project a doubling of this number by 2030 and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing care providers is a significant component of the dementia journey in most countries. Research has also shown that caring for persons with dementia can be emotionally, physically, and ethically challenging, and that turnover in nursing staff in residential care settings tends to be high. Moral distress has been explored in a variety of settings where nurses provide acute or intensive care. The concept, however, has not previously been explored in residential facility care settings, particularly as related to the care of persons with dementia. In this paper, we explore moral distress in these settings, using Nathaniel’s definition of moral distress: the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, makes a moral judgment about the correct action and yet, as a result of real or perceived constraints, cannot do what is thought to be right. We report findings from a qualitative study of moral distress in a single health region in a Canadian province. Our aim in this paper is to share findings that elucidate the sources of moral distress experienced by nursing care providers in the residential care of people living with dementia.

Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies

OBJECTIVE

To understand the prevalence of healthcare students' witnessing or participating in something that they think unethical (professionalism dilemmas) during workplace learning and examine whether differences exist in moral distress intensity resulting from these experiences according to gender and the frequency of occurrence.

DESIGN

Two cross-sectional online questionnaires of UK medical (study 1) and nursing, dentistry, physiotherapy and pharmacy students (study 2) concerning professionalism dilemmas and subsequent distress for (1) Patient dignity and safety breaches; (2) Valid consent for students' learning on patients; and (3) Negative workplace behaviours (eg, student abuse).

PARTICIPANTS AND SETTING

2397 medical (67.4% female) and 1399 other healthcare students (81.1% female) responded.

MAIN RESULTS

The most commonly encountered professionalism dilemmas were: student abuse and patient dignity and safety dilemmas. Multinomial and logistic regression identified significant effects for gender and frequency of occurrence. In both studies, men were more likely to classify themselves as experiencing no distress; women were more likely to classify themselves as distressed. Two distinct patterns concerning frequency were apparent: (1) Habituation (study 1): less distress with increased exposure to dilemmas 'justified' for learning; (2) Disturbance (studies 1 and 2): more distress with increased exposure to dilemmas that could not be justified.

CONCLUSIONS

Tomorrow's healthcare practitioners learn within a workplace in which they frequently encounter dilemmas resulting in distress. Gender differences could be respondents acting according to gendered expectations (eg, males downplaying distress because they are expected to appear tough). Habituation to dilemmas suggests students might balance patient autonomy and right to dignity with their own needs to learn for future patient benefit. Disturbance contests the 'accepted' notion that students become less empathic over time. Future research might examine the strategies that students use to manage their distress, to understand how this impacts of issues such as burnout and/or leaving the profession.

Constructing a theoretical model of moral distress

Moral distress has been characterised as one of the main ethical problems affecting nurses in all health systems, and has been depicted as a threat to nurses' integrity and to the quality of patient care. In recent years, several studies tried to investigate moral distress, its causes and consequences for health professionals, clients and organisations. However, such studies are considered controversial and vulnerable, mainly because they lack a solid philosophical and empirical basis. The present article aimed at elaborating a theoretical model for moral distress, considering the process of moral deliberation, spaces of power and resistance and patient advocacy, and sought to carry out a reflection that culminated with the creation of a broader concept of moral distress.

[Nurses, nursing technicians and assistants: who experiences more moral distress?]

OBJECTIVE

To identify the frequency and intensity of moral distress experienced by nurses, technicians and nursing assistants who worked in hospitals in the South of Rio Grande do Sul State.

METHOD

A survey research was conducted with 334 nursing workers from three institutions, through a questionnaire of moral distress. Constructs were validated through factorial analysis and Cronbach's alpha: lack of competence of the working team, disrespect to the patient's autonomy, insufficient working conditions and therapeutic obstinacy.

RESULTS

With descriptive statistics and analysis of variance, it was found that nurses and nursing assistants have higher perception of moral distress when compared to nursing technicians. Organizational questions and ways of communication influence lower perception of moral distress.

CONCLUSION

Implementation of actions to favor coping, decision making and autonomy exercise from those workers.

No place to turn: nursing students' experiences of moral distress in mental health settings

While researchers have documented the significant issue of moral distress among nurses, few have explored moral distress among mental health nurses. In addition, no research to date has explored nursing students' experiences of moral distress during mental health clinical rotations, despite nursing students typically reporting negative attitudes towards mental health nursing. This manuscript reports on a qualitative study involving seven Canadian baccalaureate nursing students, who reported on their experiences of moral distress during a 13-week clinical rotation on inpatient psychiatric units. Overall, nursing students reported significant moral distress related to the perceived lack of nurses talking meaningfully to patients on the unit, a hierarchical power structure for physicians, a lack of information given to patients about their psychiatric medications, and an inability of their nursing instructors to advocate for ethical change on the units. Several students made a specific connection between their moral distress and not wanting to pursue a career in mental health nursing.

Implicações do sofrimento moral para os(as) enfermeiros(as) e aproximações com o Burnout

Realizou-se uma revisão integrativa, com o objetivo de identificar as implicações do sofrimento moral para os(as) enfermeiros(as), aproximações entre sofrimento moral e burnout, e estratégias de enfrentamento do sofrimento moral, na literatura científica nacional e internacional publicada nos últimos 10 anos. As bases de dados foram CINAHL, MEDLINE e SAGE, e as palavras-chave, sofrimento moral, burnout e enfermagem. Obtiveram-se 21 artigos para análise, realizada em quatro etapas: redução, visualização e comparação dos dados, e verificação e esboço da conclusão. Identificou-se que o sofrimento moral vivenciado pelos(as) enfermeiros(as) manifesta-se na dimensão pessoal, com alterações emocionais e físicas, e na dimensão profissional, com insatisfação no trabalho, burnout e abandono da profissão. Constataram-se estratégias de enfrentamento em três dimensões: educativa, comunicativa e organizacional. Considera-se necessário maior exploração dessa temática, contribuindo para a prevenção do sofrimento moral.

Moral distress among Ugandan nurses providing HIV care: a critical ethnography

BACKGROUND

The phenomenon of moral distress among nurses has been described in a variety of high-income countries and practice settings. Defined as the biopsychosocial, cognitive, and behavioural effects experienced by clinicians when their values are compromised by internal or external constraints, it results from the inability to provide the desired care to patients. No research has been reported that addresses moral distress in severely resource-challenged regions such as sub-Saharan Africa.

AIM

To describe the manifestation and impact of moral distress as it was experienced by Ugandan nurses who provided care to HIV-infected or -affected people.

METHOD

A critical ethnography was conducted with 24 acute care and public health nurses at a large referral centre in Uganda. Data were collected through interviews, observation, and focus group discussions.

RESULTS

Participants described their passion for nursing and commitment to patients. They experienced moral distress when a lack of resources put patients' wellbeing at risk. The trauma imposed by systemic challenges on the nursing profession was acknowledged, as was the perception that the public blamed nurses for poor patient outcomes. However, participants were determined to serve to the best of their abilities and to take satisfaction from any contributions they were able to make. They cited the importance of education in the development of their capacity to provide care with a positive attitude, and demonstrated a collective resilience as they discussed strategies for addressing issues that affected them and their colleagues.

CONCLUSIONS

The experience of moral distress among nurses in Uganda differed somewhat from the experience of nurses in high-income countries. Constraints imposed by the inability to implement skills and knowledge to their fullest extent, as well as a lack of resources and infrastructure may result in the omission of care for patients. Moral distress appears to manifest within a relational and contextual environment and participants focussed on the impact for patients, communities, and the nursing profession as a whole, rather than on their own personal suffering. The opportunity for continuing education led to strategies to transform personal attitudes and practice as well as to enhance the presentation of the profession to the public.

Nurse burnout and stress in the NICU

The effects of nurse burnout and stress in a neonatal intensive care unit (NICU)-high levels of absenteeism, low morale, mental fatigue, and exhaustion-can have detrimental effects on neonatal care. Because of the nature of this highly specialized form of nursing, NICU nurses can experience high levels of psychologic and physical stress. Burnout is a response to workplace stress that results in emotional and mental exhaustion, depersonalization, and decreased sense of personal accomplishment. Job satisfaction, emotional support, and self-care are important components for preventing burnout in staff. Therefore, the implications regarding practice and nurse burnout in the NICU are clear. It is the responsibility of both individual nurses and administrative leaders to take the necessary steps to prevent nurse burnout. Preventing this phenomenon in the NICU can lead to better retention and recruitment rates and delivery of safe neonatal care.