Development and psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer

Evaluation of Interventions to Address Moral Distress: A Multi-method Approach

Moral distress is a well-documented phenomenon for health care providers (HCPs). Exploring HCPs' perceptions of participation in moral distress interventions using qualitative and quantitative methods enhances understanding of intervention effectiveness. The purpose of this study was to measure and describe the impact of a two-phased intervention on participants' moral distress. Using a cross-over design, the project aimed to determine if the intervention would decrease moral distress, enhance moral agency, and improve perceptions about the work environment. We used quantitative instruments and explored participants' perceptions of the intervention using semi-structured interviews. Participants were from inpatient settings, within three major hospitals of a large, urban healthcare system in the Midwest, United States. Participants included nurses (80.6%) and other clinical care providers. Using generalized linear mixed modeling we assessed the change in each of the outcome variables over time controlling for groups. Interviews were audiotaped and professionally transcribed. The written narratives were coded into themes. The change in scores on study instruments trended in the desired direction however did not meet statistical significance. Qualitative interviews revealed that intervention effectiveness was derived from a combination of learning benefits, psychological benefits, and building community that promoted moral agency. Findings demonstrate a clear link between moral distress and moral agency and suggest that Facilitated Ethics Conversations can enhance the work environment. Findings provide insight for developing evidenced-based approaches to address moral distress of hospital nurses.

Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations

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

School-Based Suicide Prevention Efforts: The Impact of School Nurse Exclusivity on Moral Distress

School nurses are well-positioned to assess, identify, and refer children and adolescents who are at risk of suicide. This multiple-case study examined the personal, behavioral, and environmental factors that influence the role of the school nurse in youth suicide prevention and intervention. Purposive sampling was used to recruit two school nurses who were identified as unique cases. Data from interviews, surveys, and documents generated a cross-case analysis. Findings indicate that school-level exclusive practices, such as a lack of communication and collaboration, greatly influence the role and reach of school nurses. Further, dilemmas arising from environmental barriers hinder school nurse capacity to promote student safety and affect moral distress levels. Leveraging data to demonstrate the pivotal role of school nurses to support mental health equity and reduce disparities in youth suicide is crucial to developing inclusive and responsive suicide prevention programs.

The inner struggle of nurses, exploring moral distress among hospital nurses: A cross-sectional study

BACKGROUND

As frontline caregivers, nurses often find themselves at the crossroads of complex ethical decisions that can significantly impact patient outcomes and their own well-being. Identifying the areas of experienced moral dilemmas in the workplace and gaining insight into the prevalence of moral distress can lead to a healthier workplace environment.

OBJECTIVE

This study aims to examine the frequency, intensity and level of moral distress among nurses who work in a hospital, and to identify the variables associated with the level of moral distress.

DESIGN

Cross-sectional study.

SETTING

One university hospital and six general hospitals.

PARTICIPANTS

654 of the 1095 nurses working on inpatient units filled out the questionnaire (response rate 60 %).

METHODS

The intensity and frequency of moral distress was assessed using the Moral Distress Scale-Revised (MDS-R). We also asked two additional questions about considering leaving their job, and if they could describe a distressing case and how moral distress was discussed. Multivariable regression analysis was conducted to identify the variables associated with the level of moral distress.

RESULTS

The overall mean MDS-R score of the 654 included nurses was low at 36.4 (SD 26). Nurses reported to have frequent dilemmas regarding organizational aspects and aspects of end-of-life care. The multivariable analyses showed that higher levels of moral distress were experienced by registered nurses, nurses working on a medical ward, and nurses who had ever left or considered leaving their job, or considering leaving their job at the moment.

CONCLUSIONS

Although nurses in our study experiences low levels of moral distress, they do experience moral dilemmas related to organizational topics and end of life care. We all need to pay attention to these dilemmas and how to discuss them in order to achieve a resilient nursing profession at a time of major nursing shortages.

TWEETABLE ABSTRACT

Caring for increasingly complex patients in a dynamic healthcare system is likely to continue to produce morally challenging scenarios.

Adaptation and validation of moral distress thermometer in Chinese nurses

BACKGROUND

Moral distress seriously affects professional nurses, and a number of instruments have been developed to measure the level of moral distress. The moral distress thermometer (MDT) is one of the commonly used instruments that can rapidly measure real-time moral distress; however, it remains unclear whether it is still useful in the Chinese cultural context.

AIM

This study aimed to adapt and validate the MDT among Chinese registered nurses.

RESEARCH DESIGN

An online, cross-sectional, survey study of adapting and validating Chinese version of MDT.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 182 registered nurses effectively finished this survey. The correlation between MDT score and the score of the moral distress scale-revised version (MDS-R) was used for evaluating convergent validity, and MDT scores of registered nurses who working in different departments and who made different actions to the final question of the MDS-R were compared by using one-way ANOVA to evaluate construct validity.

ETHICAL CONSIDERATIONS

The Ethics Committee of Chongqing Traditional Chinese Medicine Hospital approved this study.

RESULTS

The Chinese version of MDT was described as relevant to measure moral distress, with a reported item-level content validity index (I-CVI) and scale-level CVI (S-CVI) of 1. The mean MDT score and mean MDS-R score were 2.54 and 38.66, respectively, and the correlation between these two scores was significantly moderate (r = 0.41). Nurses working different departments reported different levels of moral distress, and those working in intensive care unit reported the highest level of moral distress than those working in other departments (p = 0.04). The MDT scores between nurses who presented different actions to their position were also significantly different, and those who had ever left and those who had considered leaving but did not leave reported significantly higher moral distress.

CONCLUSION

The MDT is a reliable, valid, and easy-to-use instrument to rapidly measure the real-time moral distress of registered nurses in China.

Moral distress thermometer: Swedish translation, cultural adaptation and validation

BACKGROUND

Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time.

AIM

The aim of this study was to translate the MDT and adapt it to the Swedish cultural context.

RESEARCH DESIGN

The first part of this study concerns the translation of MDT to the Swedish context, and the second part the psychometric testing of the Swedish version.

PARTICIPANTS AND RESEARCH CONTEXT

89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch's ANOVA, Games-Howell post-hoc test and Pearson's correlation analysis were done.

ETHICAL CONSIDERATIONS

The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration.

RESULTS

The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress.

CONCLUSION

The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context.

The barometer of moral distress in midwifery: A pilot study

BACKGROUND

Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery.

AIM

The aim of this study was to pilot the Barometer of Moral Distress in Midwifery.

METHODS

This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity.

FINDINGS

A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores.

DISCUSSION/CONCLUSION

This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland

PURPOSE

Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries.

DESIGN/METHODOLOGY/APPROACH

This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries.

FINDINGS

The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries.

ORIGINALITY/VALUE

Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Psychometric Evaluation of the Moral Comfort Questionnaire

Background and Purpose: The ethical challenges of the COVID-19 pandemic have contributed to an increase in moral distress (MD) in nurses-a long-standing, ubiquitous issue in nursing-highlighting its detrimental impact on nurses, patients, and healthcare organizations. MD is the negative outcome of a moral situation or dilemma in which a nurse is prevented from taking action on ethical decisions usually related to organizational constraints. On the opposite end of the spectrum, moral comfort (MC), an emerging concept in nursing, is an individual's feelings of ease with decisions and actions related to a moral dilemma or the positive outcome of a moral situation or dilemma. However, nursing literature on MC is sparse. While several instruments to measure MD exist, an instrument to measure MC was not found. The MC Questionnaire (MCQ) was theoretically developed. The purpose of this study was to conduct a psychometric evaluation of the new 35-item MCQ. Methods: Psychometric evaluation design was used. Reliability testing consisted of the examination of internal consistency (coefficient alpha values) and stability (test-retest reliability: Spearman's correlation coefficient, weighted Kappa, and Bland-Altman [B&A] analysis). Validity was examined using content validity (content expert evaluation) and discriminant validity (r < .30). Model fit of a proposed five-factor model was tested using confirmatory factor analysis (CFA). Results: Hospital-based direct-care (HB-DC) registered nurses (RNs; n = 466) participated from February 2019 to September 2019 in this Institutional Review Board-approved study. Participants completed demographic information, the MCQ, and the Moral Distress Scale-Revised (MDSR). The psychometric evaluation included a priori content validation and multiple statistical analyses: coefficient alpha, Spearman's correlation coefficient, weighted Kappa, B&A, discriminant validity, and CFA. Coefficient alpha was .951, suggesting internal consistency. Spearman's correlation coefficient was .605 (p < .001), suggesting a strong correlation between Time 1 and Time 2. Weighted Kappa values for each item (range = .139-.559) suggested slight to moderate agreement between responses over time. The B&A plot suggested agreement of responses over time. Discriminant validity results suggested no correlation between the MCQ and MDSR (r = -.219), which was expected. CFA results suggest a poor model fit of the proposed five-factor model. A post hoc hierarchical cluster analysis showed the presence of two clusters. A subsequent two-factor exploratory factor analysis showed items loading onto one of the two factors (internal and external). Conclusions: MC in nurses is essential to promoting positive outcomes for nurses. An instrument to measure MC in nurses is needed to gain a further understanding of the concept. The MCQ was theoretically developed and psychometrically evaluated. Results suggest the validity and reliability of the MCQ with further testing of a two-factor model. Knowledge acquired from studies using the MCQ could potentially be used to develop strategies to promote MC in nurses, thereby promoting positive outcomes for nurses, patients, and healthcare organizations.

Critical care nurse leaders' moral distress: A qualitative descriptive study

BACKGROUND

Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL's experience.

RESEARCH AIM

The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress.

RESEARCH DESIGN

A qualitative descriptive design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection.

PARTICIPANT AND RESEARCH CONTEXT

Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023.

ETHICAL CONSIDERATIONS

This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection.

FINDINGS

UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress.

CONCLUSIONS

The UBCCNL's experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed.

Stress, resilience, and moral distress among health care providers in oncology during the COVID-19 pandemic

Background

The coronavirus pandemic has potential implications for stress levels and resilience among oncology healthcare professionals (HCPs). This study aims to assess perceived stress, resilience, and moral distress levels among oncology HCPs in Jordan during the pandemic and identify associated risk factors.

Methods

An online cross-sectional survey was conducted among oncology HCPs in Jordan using three validated tools: Perceived Stress Scale (PSS), Connor-Davidson Resilience Scale (CD-RSIC), and Moral Distress Thermometer (MDT). Seven items were used to assess sources of stress.

Results

A total of 965 participants enrolled with a 74% response rate. The participants' ages ranged from 20 to 74 (mean = 32.74, SD = 5.197), with 79.1% males, 45.1% were physicians, 32.6% were public hospital workers, 57.1% were married, and 56.6% had children below 18 years. Findings indicated moderate perceived stress (Mean = 15.87, SD = 5.861), low resilience (Mean = 29.18, SD = 5.197), and high moral distress (Mean = 4.72, SD = 2.564). Females, unmarried individuals, and younger age groups exhibited higher PSS (p = 0.009, p < 0.001, and P<0.001) and lower resilience (p = 0.024, p = 0.034, and p = 0.001). Not having children below 18 years correlated with higher perceived stress (P < 0.001). In linear regression analysis, age and gender emerged as significant predictors of both perceived stress and resilience. Female participants reported stress related to the risk of contracting COVID-19 (p = 0.001), transmitting it to others (p = 0.017), social isolation (P < 0.001), and having children at home due to school closures (p = 0.000). A cohort of 239 participants repeated the survey within a two-month interval, revealed a statistically significant decrease in the CD-RISC scores (p < 0.001).

Conclusion

Oncology HCPs in Jordan experienced moderate stress, high moral distress, and poor resilience during the COVID-19 pandemic. These factors may negatively affect the quality of oncology care. Urgent measures are necessary to support HCPs in coping with unforeseen circumstances in the future.

Caring for patients during voluntarily stopping of eating and drinking (VSED): experiences of a palliative care team in Germany

BACKGROUND

Health-care professionals are confronted with patients who wish to end their lives through voluntarily stopping eating and drinking (VSED). During VSED, symptoms such as agitation, thirst or psychological distress may arise, thus making close medical accompaniment necessary. Dealing with these symptoms can put a high burden on palliative care teams. Furthermore, divergent perceptions of the ethical classification of VSED may lead to moral distress. The aim of this study was to assess the influence of experience gained over time on the burden of palliative care professionals while accompanying patients during VSED and to assess the perceptions of coping strategies.

METHODS

This is a prospective single-centre study conducted at the Interdisciplinary Centre for Palliative Care at University Hospital Duesseldorf, Germany. At two points in time (T1, T2) one year apart, team members of all professions who were actively involved in the accompaniment were eligible to complete a pretested questionnaire.

RESULTS

Team members perceived the symptom complex of psychological distress, anxiety, and agitation to be the most burdensome symptoms for the patients (T1: 28/49, 57.1%; T2: 33/59, 55.9%). Thirst was the second most observed symptom (T1: 17/49, 34.7%, T2: 19/59, 32.2%). These were also the most burdensome symptoms for individual team members. Most team members found there were no general moral concerns. There was a decrease in the perceived importance of support strategies such as ethical counselling (85.7% versus 63.6%).

CONCLUSIONS

Accompanying patients during VSED is a challenge for health-care professionals. When comparing T2 to T1, less emphasis lies on the importance of ethical counselling or psychiatric assessment to build a foundation for the accompaniment. Moral and ethical concerns seem to play a minor role. More in-depth studies covering a bigger sample size as well as qualitative studies are needed.

Politicization of Medical Care, Burnout, and Professionally Conflicting Emotions Among Physicians During COVID-19

OBJECTIVE

To evaluate the association of politicization of medical care with burnout, professional fulfillment, and professionally conflicting emotions (eg, less empathy, compassion; more anger, frustration, resentment).

PARTICIPANTS AND METHODS

Physicians in select specialties were surveyed between December 2021 and January 2022 using methods similar to our prior studies, with additional assessment of politicization of medical care; moral distress; and having had to compromise professional integrity, workload, and professionally conflicting emotions.

RESULTS

In a sample of 2780 physicians in emergency medicine, critical care, noncritical care hospital medicine, and ambulatory care, stress related to politicization of medical care was reported by 91.8% of physicians. On multivariable analysis, compromised integrity (odds ratio [OR], 3.64; 95% CI, 2.31 to 5.98), moral distress (OR, 2.82; 95% CI, 2.16 to 3.68), and feeling more exhausted taking care of patients with coronavirus disease 2019 (COVID-19) (OR, 3.46; 95% CI, 2.63 to 4.54) were associated with burnout. Compromised integrity, moral distress, and feeling more exhausted taking care of patients with COVID-19 were also statistically significantly associated with lower odds of professional fulfillment and professionally conflicting emotions. Stress related to conversations about non-approved COVID-19 therapies (OR, 1.74; 95% CI, 1.08 to 2.89), patient resistance to mask wearing (OR, 1.84; 95% CI, 1.35 to 2.55), and working more hours due to COVID (OR, 0.66; 95% CI, 0.49 to 0.89) were associated with professionally conflicting emotions.

CONCLUSION

Most physicians experienced intrusion of politics into medical care during the pandemic. These experiences are associated with professionally conflicting emotions, including less compassion and empathy, greater frustration, and resentment. COVID-19-related moral distress and compromised integrity were also associated with less professional fulfillment and greater occupational burnout.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic

CONTEXT

PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice.

HYPOTHESIS

RFP policies negatively impacted families of PICU patients and caused moral distress.

METHODS AND MODELS

National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis.

RESULTS

Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside.

INTERPRETATIONS AND CONCLUSIONS

Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Early career nurses and moral distress: An integrative review

AIM

The purpose of this integrative review was to evaluate and synthesize literature published in peer-reviewed journals within the past 40 years addressing moral distress in early career nurses (graduation to five years of experience).

BACKGROUND

Moral distress experienced in nursing education and practice manifests physically and psychologically, leads to workforce burnout and attrition, and compounds the nursing shortage. The transition to practice period is a vulnerable time for student nurses emerging into professional practice. Nurse educators serve a crucial role in the preparation of nurses for the recognition and management of moral distress in their professional nursing practice. A better understanding of the state of the science pertaining to the reports of moral distress in early career nurses is essential.

DESIGN

Whittemore and Knafl's Integrative Review method and the PRISMA 2020 Checklist were utilized in this integrative review.

METHODS

Five literature databases (CINAHL, ERIC, PsychInfo, PubMed, and Embase) were searched using 'moral distress' and 'new graduate nurses' as keywords. Studies were included for English language; qualitative and quantitative research; moral distress focus; years of nursing practice experience collected and analyzed in results or discussion; and all areas of clinical nursing practice, geographic locations, and nursing education levels. Studies were excluded for non-peer reviewed publications; moral distress in the academic setting; and the absence of analysis of years of nursing practice experience in the results or discussion.

RESULTS

Eight primary research reports, published between 2016 and 2022 met eligibility criteria. Research methods were largely quantitative with six countries geographically represented. Acute care healthcare settings had the greatest representation with considerations for the COVID-19 pandemic in two reports. Various formats of four moral distress research instruments were used. Years of nursing practice experience were collected as a mean or category. Inconsistent reports of moral distress in early career nurses were found based on experience, age, or nursing education level.

CONCLUSIONS

Research of moral distress prevalence in early career nurses was an identified literature gap. Varied reports of moral distress in early career nurses indicate a need to further understand this topic contextual to academic and clinical education. Nurse educators can prepare students for experiences of moral distress in their professional nursing practice by implementing teaching strategies that draw upon their diverse backgrounds and experiences. A research and education emphasis on moral distress in early career nurses can promote their transition to practice, support their career progression, and uphold nursing occupational commitment.

TWEETABLE ABSTRACT

An integrative review of moral distress in early career nurses found inconsistent reports of moral distress in this population and a need for further research.

Prevalence and Risk Factors for Moral Distress in Pediatric Oncology Health Care Professionals

PURPOSE

Moral distress (MoD) is prevalent among health care professionals (HCPs) in oncology and is associated with burnout. The objectives of this study were to quantify MoD among pediatric oncology healthcare professionals (HCPs) at a Canadian quaternary care hospital, identify root causes, and evaluate change over time.

METHODS

Eligible pediatric oncology HCPs were identified, and consenting participants completed the Measure of Moral Distress-Healthcare Professionals (MMD-HP) and MoD Thermometer (MDT) at baseline, followed by biweekly MDTs over 12 weeks.

RESULTS

A total of 139 HCPs participated. The mean MMD-HP score was 123 ± 57.0, range 9-288. Demographic risk factors identified for elevated MMD-HP scores were female sex (female 127.1 and male 83.6, P = .01) and nursing role (nurse 136.3 and most responsible physician 85.3, P = .02). Higher MMD-HP scores were found in HCPs who were currently considering resigning because of MoD compared with those who were not (169.9 v 115.4, P < .001). Situations involving administration of treatment to children with poor prognosis cancers that was perceived to be overly aggressive were ranked as the greatest environmental contributor to MoD. Baseline and mean MDT scores over time strongly correlated with MMD-HP scores (P < .0001 and P = .0003, respectively), with mean MDT scores showing no significant fluctuation over the 12-week period.

CONCLUSION

MoD was common among pediatric oncology HCPs. Risk factors for elevated levels of MoD included both demographic and environmental factors. Implementation of systems to improve team communication and decision making, especially in the care of patients with poor prognosis cancers, may affect HCP MoD.

A survey of pediatric intensive care unit clinician experience with restricted family presence during COVID-19

PURPOSE

Limiting family presence runs counter to the family-centred values of Canadian pediatric intensive care units (PICUs). This study explores how implementing and enforcing COVID-19-related restricted family presence (RFP) policies impacted PICU clinicians nationally.

METHODS

We conducted a cross-sectional, online, self-administered survey of Canadian PICU clinicians to assess experience and opinions of restrictions, moral distress (Moral Distress Thermometer, range 0-10), and mental health impacts (Impact of Event Scale [IES], range 0-75 and attributable stress [five-point Likert scale]). For analysis, we used descriptive statistics, multivariate regression modelling, and a general inductive approach for free text.

RESULTS

Representing 17/19 Canadian PICUs, 368 of 388 respondents (94%) experienced RFP policies and were predominantly female (333/368, 91%), English speaking (338/368, 92%), and nurses (240/368, 65%). The mean (standard deviation [SD]) reported moral distress score was 4.5 (2.4) and was associated with perceived differential impact on families. The mean (SD) total IES score was 29.7 (10.5), suggesting moderate traumatic stress with 56% (176/317) reporting increased/significantly increased stress from restrictions related to separating families, denying access, and concern for family impacts. Incongruence between RFP policies/practices and PICU values was perceived by 66% of respondents (217/330). Most respondents (235/330, 71%) felt their opinions were not valued when implementing policies. Though respondents perceived that restrictions were implemented for the benefit of clinicians (252/332, 76%) and to protect families (236/315, 75%), 57% (188/332) disagreed that their RFP experience was mainly positive.

CONCLUSION

Pediatric intensive care unit-based RFP rules, largely designed and implemented without bedside clinician input, caused increased psychological burden for clinicians, characterized as moderate moral distress and trauma triggered by perceived impacts on families.

Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.

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.

Sub-categories of moral distress among nurses: A descriptive longitudinal study

BACKGROUND

There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard "narrow" definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown.

RESEARCH AIMS

To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument.

RESEARCH DESIGN

A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6 weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data.

PARTICIPANTS

Registered nurses from four hospitals within one large healthcare system in Midwest United States.

ETHICAL CONSIDERATIONS

IRB approval was obtained.

RESULTS

246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by "other" distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation.

CONCLUSIONS

Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.

Distress and the Long-Stay Pediatric Intensive Care Unit Admission: A Longitudinal Study of Parents and the Medical Team

Prolonged critical illness in children has emotional consequences for both parents and providers. In this observational cohort study, we longitudinally surveyed anxiety and depression in parents and moral distress in pediatric intensive care unit (PICU) providers (attendings, fellows, and bedside registered nurses) and explored their trajectories and relationships. Anxiety/depression and provider moral distress were measured using the Hospital Anxiety and Depression Scale and the Moral Distress Thermometer, respectively. The relationships of parental and provider distress were evaluated using Spearman's correlations, and their trajectories and potentially associated variables were explored using quadratic random slope and intercept models. Predetermined associated factors included demographic and clinical factors, including parent psychosocial risk and intubation status. We found parental anxiety and depression decreased over their child's admission, and parental psychosocial risk was significantly associated with anxiety (coefficient = 4.43, p  < 0.001). Clinicians in different roles had different mean levels and trajectories of moral distress, with fellows reporting greater distress early in admissions and nurses later in admissions. Parental anxiety/depression and provider distress were significantly, though moderately, correlated. We conclude that anxiety and depression in parents of children with prolonged PICU admissions and the moral distress of their clinicians correlate and vary over time and by provider role.

A Novel Web-Based and Mobile Application to Measure Real-Time Moral Distress: An Initial Pilot and Feasibility Study

PROBLEM DEFINITION

Moral distress (MoD) is a vital clinical indicator linked to clinician burnout and provider concerns about declining patient care quality. Yet it is not routinely assessed. Earlier, real-time recognition may better target interventions aimed at alleviating MoD and thereby increase provider well-being and improve patient care quality.

INITIAL APPROACH AND TESTING

Combining two validated MoD instruments (the Moral Distress Thermometer [MDT] and the Measure of Moral Distress for Healthcare Professionals [MMD-HP]), the authors developed a novel mobile and Web-based application environment to measure and report levels MoD and their associated causes. This app was tested for basic feasibility and acceptability in two groups: graduate nursing students and practicing critical care nurses.

RESULTS

The MDT app appears feasible and acceptable for future use. All participants (n = 34) indicated the MDT app was satisfying to use, and 91.2% (n = 31) indicated the app was "very appropriate" for measuring MoD. In addition, 84.2% (n =16) of practicing nurses indicated the app fit either "somewhat well" (47.4%, n = 9) or "very well" (36.8%, n = 7) into their typical workday, and 68.4% (n = 13) said they were either "extremely likely" or "somewhat likely" to use the app daily in clinical practice.

KEY INSIGHTS AND NEXT STEPS

Education about moral distress and its associated causes proved important to the MDT app's success. It is ready for future validity and reliability testing, as well as examining usability beyond nursing, longitudinal data monitoring, and possible leveraging to pre- and postintervention evaluation studies.

The value of nurse bioethicists

BACKGROUND

The field of nursing has long been concerned with ethical issues. The history of the nursing profession has a rich legacy of attention to social justice and to societal questions regarding issues of fairness, access, equity, and equality. Some nurses have found that their clinical experiences spur an interest in ethical patient care, and many are now nurse bioethicists, having pursued additional training in bioethics and related fields (e.g., psychology, sociology).

PURPOSE

The authors describe how the clinical and research experiences of nurses give them a unique voice in the field of bioethics.

RESULTS

Authors present reasons for the relative invisibility of nurse bioethicists, compared with physician, theologian, or philosopher bioethicists, as well as current efforts to increase the visibility of nurse bioethicists. They also describe four specific areas where nurse bioethicists have made and continue to make important contributions: as ethics consultants to colleagues in hospitals and other settings; as bioethics researchers or as advisers to researchers conducting trials with human subjects; as educators of trainees, patients and families, healthcare providers, and the public; and in helping to draft humane and ethical policies for the care of vulnerable patients and underserved populations.

CONCLUSION

Nurse bioethicists are central to the future goals of healthcare bringing a unique perspective to the day-to-day ethical challenges of both clinical care and research, as well as to the education of health professionals and the public.

Mental burden and moral distress among oncologists and oncology nurses in Germany during the third wave of the COVID-19 pandemic: a cross-sectional survey

PURPOSE

There is evidence for mental burden and moral distress among healthcare workers during the pandemic. However, there is scarcity of analyses regarding possible correlations of mental burden and moral distress in this context. This study provides data to quantify mental burden and possible associations with moral distress among physicians and nurses working in oncology in Germany.

METHODS

We conducted a cross-sectional online survey with physicians and nurses working in oncology in Germany between March and July 2021. Next to sociodemographic characteristics and working conditions, mental burden and moral distress were assessed using standardized instruments. Binary multivariate logistic regression using the enter method was performed in order to explore the relationship between mental burden and moral distress.

RESULTS

121 physicians and 125 nurses were included in the study. Prevalence of clinically relevant depressive symptoms, anxiety, somatic symptoms, burnout symptoms and moral distress was 19.2, 14.5, 12.7, 46.0 and 34.7% in physicians and 41.4, 24.0, 46.8, 46.6 and 60.0% in nurses respectively. Mental burden was significantly associated with moral distress, being female/diverse, younger age < 40 and increase in workload. Nurses who felt sufficiently protected from COVID-19 reported significantly less moral distress.

CONCLUSION

To improve pandemic resilience, there is a need to ensure safe working environment including psychosocial support. Further evidence on risk and protective factors for moral distress is needed to be able to develop and implement strategies to protect healthcare workers within and beyond the pandemic.

The relationship between emotional labor level and moral distress

BACKGROUND

The coronavirus disease (COVID-19) pandemic has implications for health professionals.

AIM

The aim of this study was to explain the relationship between emotional labor levels and moral distress in health professionals during the COVID-19 pandemic using the Structural Equation Modeling (SEM) technique.

RESEARCH DESIGN

A descriptive and cross-sectional study was adopted.

PARTICIPANTS AND RESEARCH CONTEXT

Data were collected between 7 February and 7 March 2021. 302 health professionals who were not on leave (annual leave, sick leave, prenatal and postnatal leave, etc.) at the time of the research and who volunteered to participate in the research were included. Research data were collected using a "Personal Information Form," the "Emotional Labor Scale" and the "Moral Distress Thermometer."

ETHICAL CONSIDERATIONS

The Ethics Committee approved the study (dated 07.01.2021 and numbered 2021/1-3). The participants were informed of the study aim and written consent was obtained before completing the survey.

FINDINGS

In the present study, the mediator role of emotional labor in the effect of providing service to a patient with COVID-19 and having had COVID-19 on moral distress was examined in health professionals and it was found that there was a correlation between providing service to a patient with COVID-19 and moral distress regardless of whether or not emotional labor had a role in this relationship.

CONCLUSION

In this study, the relationship between the level of emotional labor and moral distress in health professionals during the COVID-19 pandemic was evaluated with a structural equation model.

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

BACKGROUND

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

LOCAL PROBLEM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychometric testing of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP)

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.

Spanish psychometric properties of the moral distress scale-revised: a study in healthcare professionals treating COVID-19 patients

BACKGROUND

Moral distress appears when a healthcare professional is not able to carry out actions in accordance with their professional ethical standards. The Moral Distress Scale-Revised is the most widely used to assess levels of moral distress, but it is not validated in Spanish. The aim of the study is to validate the Spanish version of the Moral Distress Scale - utilised within a sample of Spanish healthcare professionals treating COVID-19 patients.

METHODS

The original (english) and the portuguese and french versions of the scale were translated into spanish by native or bilingual researchers and reviewed by an academic expert in ethics and moral philosophy as well as by a clinical expert.

RESEARCH DESIGN

Descriptive cross-sectional study carried out using a self-reporting online survey. The data was collected between June- November 2020. A total of 661 professionals responded to the survey (N = 2873).

PARTICIPANTS

healthcare professionals with more than two weeks of experience treating COVID-19 patients at the end of their life and working in the public sector of the Balearic Islands Health Service (Spain). Analyses included descriptive statistics, competitive confirmatory factor analysis, evidence on criterion-related validity and estimates of reliability. The study was approved by the Research Ethics Committee at the University of Balearic Islands.

RESULTS

An unidimensional model in which a general factor of moral distress explained by 11 items of the Spanish version of the MDS-R scale was an adequate representation of the data: χ²(44) = 113.492 (p 0.001); Comparative Fit Index = 0.965; Root Mean Square Error of Approximation = 0.079[0.062,0.097]; and Standarized Root Mean-Square = 0.037. Evidence of reliability was excellent: Cronbach's alpha = 0.886 and McDonald's omega = 0.910. Moral distress was related to discipline, with nurses having statistically significant higher levels than physicians. Additionally, moral distress successfully predicted professional quality of life, with higher levels of moral distress being related to poorer quality of life.

CONCLUSIONS

The Spanish version of Moral Distress Scale-Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by health professionals. This tool will be highly useful for managers and applicable to a variety of healthcare professionals and settings.

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students

BACKGROUND

Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention.

PURPOSE

The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students.

METHODS

This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States.

FINDINGS

The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level.

CONCLUSION

All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

The Mindful Ethical Practice and Resilience Academy: Sustainability of Impact

BACKGROUND

Nurses face many ethical challenges, placing them at risk for moral distress and burnout and challenging their ability to provide safe, high-quality patient care. Little is known about the sustainability of interventions to address this problem.

OBJECTIVE

To determine the long-term impact on acute care nurses of a 6-session experiential educational program called the Mindful Ethical Practice and Resilience Academy (MEPRA).

METHODS

MEPRA includes facilitated discussion, role play, guided mindfulness and reflective practices, case studies, and high-fidelity simulation training to improve nurses' skills in mindfulness, resilience, and competence in confronting ethical challenges. A prospective, longitudinal study was conducted on the impact of the MEPRA curriculum at 2 hospitals in a large academic medical system. The study involved surveys of 245 nurses at baseline, immediately after the intervention, and 3 and 6 months after the intervention.

RESULTS

The results of the intervention were generally sustained for months afterward. The most robust improvements were in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger. Some outcomes were not improved immediately after the intervention but were significantly improved at 3 months, including anxiety and empathy. Depersonalization and turnover intentions were initially reduced, but these improvements were not sustained at 6 months.

CONCLUSIONS

Many MEPRA results were sustained at 3 and 6 months after conclusion of the initial foundational program. Some outcomes such as depersonalization and turnover intentions may benefit from boosters of the intervention or efforts to supplement the training by making organizational changes to the work environment.

Moral Distress: What Are We Measuring?

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals' moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change.

Moral Distress in the ICU: Measuring, Tracking, and Responding to Staff Experiences

Until the surges of COVID-19 patients overwhelmed our health care system, moral distress was largely unknown outside of health care. We conducted a study in a 36-bed intensive care unit (ICU) over an 8-week period to determine the severity and contributing factors to clinicians’ moral distress and how their moral distress impacted intent to leave, and to assess utilization of resources to mitigate the problem. This article describes the level of moral distress experienced by ICU staff, the disparity between hospital-provided resources and the contributing factors of moral distress, and the potential financial cost of job turnover due to moral distress.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the well-being of community pharmacy professionals, turnover intention, and patient safety: Time to include operational responsibility

Background:

The COVID-19 pandemic added significant occupational pressures on community pharmacists. The objective of this research project was to investigate the level of distress and burnout among community pharmacy professionals and its association with their retention within their occupation as well as patient safety outcomes.

Method:

We conducted a cross-sectional study on 722 community pharmacy professionals from all Canadian provinces using an online survey, including scientifically validated measures. The data were analyzed using multiple regression analysis.

Results:

In Canada, 85% of community pharmacy professionals reported their mental health had suffered since the COVID-19 pandemic. Younger pharmacy professionals and those paid hourly reported a worsening level of mental health and an increasing level of turnover intention. Pharmacists with more dynamic/disrupted work schedules and those working for a large pharmacy chain (more than 25 pharmacies in Canada) reported lower levels of mental health quality. Pharmacy professionals working in pharmacies that are open more than 70 hours a week reported a lower level of patient safety culture. Pharmacists’ mental health was the significant predictor of their turnover intention, implying a heightened risk to professional effectiveness and retention. Compassion satisfaction was positively associated with patient safety culture and safety behaviour, while compassion fatigue and secondary traumatic stress were significantly associated with pharmacists’ level of risk-taking behaviours.

Conclusion:

This study emphasized the importance of prioritizing the mental health and well-being of community pharmacy professionals and demonstrated individual and systemic factors predicting the well-being and turnover intention of community pharmacists, as well as patient safety culture within their pharmacy. This research makes a case to consider actions to shift the monitoring focus from community pharmacists (also known as “individual responsibility”) to community pharmacies (also known as “operational responsibility”) for managing patient safety. Additionally, community pharmacists should be provided with the professional autonomy to affect their working conditions and alleviate the stress that has the potential to negatively affect the delivery of care.

Moral distress to moral success: Strategies to decrease moral distress

BACKGROUND

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

AIM

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

DESIGN

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

PARTICIPANTS

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

ETHICAL CONSIDERATIONS

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

FINDINGS

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

DISCUSSION

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

CONCLUSIONS

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

Psychological distress among healthcare providers in oncology during the COVID-19 pandemic in Japan: The mediating role of moral distress and resilience

Objective

Even though vaccines have become widespread, there is an explosion of infection due to the emergence of new mutant strains, and support for healthcare providers' mental health is necessary. The aims of this study were to explore factors associated with the psychological distress, and to determine the degree of association between moral distress, resilience and psychological distress in order to consider intervention models for psychological distress of healthcare providers involved with cancer patients during the COVID-19 pandemic.

Method

We conducted a cross-sectional survey among healthcare providers at the National Cancer Center, Japan. Psychological distress was assessed by the Hospital Anxiety and Depression Scale. We also assessed moral distress using the Moral Distress Thermometer and resilience using the Connor-Davidson Resilience Scale 10 in April and May 2020 which was the first surge of the epidemic period.

Results

Five hundred sixty-six of 3,900 healthcare providers (14.5%) responded. Sixty-eight percent (385/566) responders were above the Hospital Anxiety and Depression Scale cutoff. Hierarchical regression analyses indicated that nurses, allied health professionals and office workers/engineers (odds ratio = 4.63; 95% confidence interval 1.90-11.29; p < 0.001, odds ratio = 3.88; 95% confidence interval 1.88-8.00; p < 0.001, odds ratio = 2.10; 95% confidence interval 1.06-4.18; p < 0.05) as well as healthcare providers with low resilience (odds ratio = 0.88; 95% confidence interval 0.85-0.91; p < 0.001) were at risk of psychological distress. Moral distress was not significantly associated with prevalence of psychological distress.

Conclusion

During the first surge of the pandemic, a high prevalence of psychological distress was demonstrated among cancer center healthcare providers. The study suggests that mental health care should be available to cancer care providers. Since the COVID-19 pandemic is still going on, in addition to the efforts by our facilities, we should consider interventions that promote resilience and a feasibility study of these interventions.

Moral distress and patients who forego care due to cost

BACKGROUND

In the US, many patients forgo recommended care due to cost. The ANA Code of Ethics requires nurses to give care based on need. Therefore, US nurses are compelled to practice in a context which breaches their professional ethical code.

RESEARCH OBJECTIVES

This study sought to determine if nurses do care for patients who forgo treatment due to cost (PFTDC) and if so, does this result in an experience of moral distress (MD).

RESEARCH DESIGN

Semi-structured interviews were transcribed and analyzed using a qualitative content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

A convenience sample of 20 nurses in practice for at least one year from a variety of health care setting participated.

ETHICAL CONSIDERATIONS

This project was approved by the Michigan State University Biomedical Institutional Review Board.

RESULTS

There were 19 female and one male nurse-participants, averaging 47 years old with an average of 10 years in practice. 18 reported caring for PFTDC. These 17 nurse-participants experienced a moderate degree of MD as a result, averaging 5.4 of 10 on the Moral Distress Thermometer. In the interviews, the following themes were identified, strategies to help PFTDC, and the broken US health care system which had the subthemes of preference for business over patient-oriented benefit, PFTDC using the emergency department, and limited support for treatment/management of PFTDC.

CONCLUSIONS

The existence of this phenomenon places the profession of nursing in the US in a position of moral compromise and threatens to corrupt the institution of nursing in the US.

A descriptive study of the multidisciplinary healthcare experiences of inpatient resuscitation events

Background

In-hospital resuscitation events have complex and enduring effects on clinicians, with implications for job satisfaction, performance, and burnout. Ethically ambiguous cases are associated with increased moral distress. We aim to quantitatively describe the multidisciplinary resuscitation experience.

Methods

Multidisciplinary in-hospital healthcare professionals at an adult academic health center in the Midwestern United States completed surveys one and six weeks after a resuscitation event. Surveys included demographic data, task load (NASA-TLX), overall and moral distress, anxiety, depression, and spiritual peace. Spearman's rank correlation was computed to assess task load and distress.

Results

During the 5-month study period, the study included 12 resuscitation events across six inpatient units. Of 82 in-hospital healthcare professionals eligible for recruitment, 44 (53.7%) completed the one-week post-resuscitation event survey. Of those, 37 (84.1%) completed the six-week survey. Highest median task load burden at one week was seen for temporal demand, effort, and mental demand. Median moral distress scores were low, while "at peace" median scores tended to be high. There were no significant non-zero changes in task load or distress scores from weeks 1-6. Mental demand (r = 0.545, p < 0.001), physical demand (r = 0.464, p = 0.005), performance (r = -0.539, p < 0.001), and frustration (r = 0.545, p < 0.001) significantly correlated with overall distress. Performance (r = -0.371, p = 0.028) and frustration (r = 0.480, p = 0.004) also significantly correlated with moral distress.

Conclusions

In-hospital healthcare professionals' experiences of resuscitation events are varied and complex. Aspects of task load burden including mental and physical demand, performance, and frustration contribute to overall and moral distress, deserving greater attention in clinical contexts.

Sprinting in a Marathon: Nursing Staff and Nurse Leaders Make Meaning of Practicing in COVID-19 Devoted Units Pre-Vaccine

Objective

To describe the lived experience of nursing staff and nurse leaders working in COVID-19 devoted units (intensive care or medical unit) prior to vaccine availability.

Research Design

Qualitative phenomenological design with a focus group approach.

Methods

The study team recruited a convenience sample of nursing staff (nurses, and nursing assistants/nurse technicians) and nurse leaders (managers, assistant nurse managers, clinical nurse specialists, and nurse educators) at an academic medical center in the midwestern United States. Focus groups and individual interviews were conducted to encourage participants to describe their (1) experiences as nursing professionals, (2) coping strategies, and (3) perspectives about supportive resources. Moral distress was measured with the moral distress thermometer and qualitative data were analyzed with Giorgi-style phenomenology.

Results

We conducted 10 in-person focus groups and five one-on-one interviews ( n  =  44). Seven themes emerged: (1) the reality of COVID-19: we are sprinting in a marathon; (2) acute/critical care nurse leaders experience unique burdens; (3) acute/critical care staff nurses experience unique burdens; (4) meaning of our lived experience; (5) what helped us during the pandemic; (6) what hurt us during the pandemic; and (7) we are not okay. Participants reported a moderate level of moral distress ( M  =  5.26 SD  =  2.31). They emphasized that peer support was preferred over other types of support offered by the healthcare organization. Participants expressed positive feedback about the focus group experience and commented that group processing validated their experiences and helped them “feel heard.”

Conclusion

These findings affirm the need for trauma-informed care and grief support for nurses, interventions that increase meaning in work, and efforts to enhance primary palliative communication skills. Study findings can inform efforts to tailor existing interventions and develop new, more comprehensive resources to meet the psychosocial needs of nursing staff and nurse leaders practicing during a pandemic.

Palliative and hospice social workers' moral distress during the COVID-19 pandemic

OBJECTIVES

Moral distress is associated with adverse outcomes contributing to health-care professionals' worsened mental and physical well-being. Medical social workers have been frontline care providers throughout the COVID-19 pandemic, and those specializing in palliative and hospice care have been particularly affected by the overwhelming numbers of those seriously ill and dying. The main objectives of this study were (1) to assess palliative and hospice social workers' experiences of moral distress during COVID-19 and (2) to identify and describe participants' most morally distressing scenarios.

METHODS

Using a mixed-methods approach, participants completed an online survey consisting of the Moral Distress Thermometer (MDT) and open-ended text responses.

RESULTS

A total of 120 social work participants responded to the study, and the majority of participants (81.4%) had experienced moral distress with an average MDT score of 6.16. COVID-19 restrictions emerged as the main source of moral distress, and an overlap between the clinical and system levels was observed. Primary sources of moral distress were grounded in strict visitation policies and system-level standards that impacted best practices and personal obligations in navigating both work responsibilities and safety.

SIGNIFICANCE

In the first year of the COVID-19 pandemic, palliative and hospice social work participants indicated high levels of moral distress. Qualitative findings from this study promote awareness of the kinds of distressing situations palliative and hospice social workers may experience. This knowledge can have education, practice, and policy implications and supports the need for research to explore this aspect of professional social work.

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

GOAL

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

METHODS

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

PRINCIPAL FINDINGS

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

PRACTICAL APPLICATIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Moral distress among clinicians working in US safety net practices during the COVID-19 pandemic: a mixed methods study

OBJECTIVE

To explore the causes and levels of moral distress experienced by clinicians caring for the low-income patients of safety net practices in the USA during the COVID-19 pandemic.

DESIGN

Cross-sectional survey in late 2020, employing quantitative and qualitative analyses.

SETTING

Safety net practices in 20 US states.

PARTICIPANTS

2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes.

MEASURES

Ordinally scaled degree of moral distress experienced during the pandemic, and open-ended response descriptions of issues that caused most moral distress.

RESULTS

Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported 'mild' or 'uncomfortable' levels and 26.8% characterised their moral distress as 'distressing', 'intense' or 'worst possible'. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress.

CONCLUSIONS

During the pandemic's first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-quarter was this significantly distressing. As reported for hospital-based clinicians during the pandemic, this study's clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians' moral distress from witnessing inequities and other injustices for their patients and communities.

Understanding Moral Distress among Eldercare Workers: A Scoping Review

The aging of the population in Western countries will increase the use of social and health services in the future. Employees in eldercare are at risk for experiencing moral distress, which is associated with poor work ability. The causes and consequences of moral distress among eldercare workers remain undiscovered. This scoping review investigates the existing studies of causes and consequences of moral distress among eldercare workers. Additionally, it seeks evidence of interventions designed to mitigate moral distress in eldercare workers. Fourteen studies were included in the final review. Most of the included studies were qualitative, aiming to increase understanding of morally challenging situations in eldercare. We also found quantitative studies with cross-sectional designs and small sample sizes. Thus, no reliable evidence of causal effects between moral distress and worker wellbeing in eldercare was found. We found no interventions undertaken to resolve moral distress among eldercare workers, either. More research is needed on the causes and consequences of moral distress and on interventions to mitigate moral distress among eldercare workers. This is of utmost importance to increase the attractiveness of eldercare as a workplace and to improve eldercare workers’ ability to work and sustain long working careers.

A national study of moral distress among U.S. internal medicine physicians during the COVID-19 pandemic

Background

There have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress.

Methods

We conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales.

Results

The response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care.

Conclusions

The intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

Protecting the mental and physical well-being of frontline health care workers during COVID-19: Study protocol of a cluster randomized controlled trial

Introduction

The COVID-19 pandemic has placed health care workers at unprecedented risk of stress, burnout, and moral injury. This paper describes the design of an ongoing cluster randomized controlled trial to compare the effectiveness of Stress First Aid (SFA) to Usual Care (UC) in protecting the well-being of frontline health care workers.

Methods

We plan to recruit a diverse set of hospitals and health centers (eight matched pairs of hospitals and six pairs of centers), with a goal of approximately 50 HCW per health center and 170 per hospital. Participating sites in each pair are randomly assigned to SFA or UC (i.e., whatever psychosocial support is currently being received by HCW). Each site identified a leader to provide organizational support of the study; SFA sites also identified at least one champion to be trained in the intervention. Using a “train the trainer” model, champions in turn trained their peers in selected HCW teams or units to implement SFA over an eight-week period. We surveyed HCW before and after the implementation period. The primary outcomes are posttraumatic stress disorder and general psychological distress; secondary outcomes include depression and anxiety symptoms, sleep problems, social functioning problems, burnout, moral distress, and resilience. In addition, through in-depth qualitative interviews with leaders, champions, and HCW, we assessed the implementation of SFA, including acceptability, feasibility, and uptake.

Discussion

Results from this study will provide initial evidence for the application of SFA to support HCW well-being during a pandemic.

Trial registration: (Clinicaltrials.govNCT04723576).

Ethical decision-making confidence scale for nurse leaders: Psychometric evaluation

Background

Ethical decision-making confidence develops from clinical expertise and is a core competency for nurse leaders. No tool exists to measure confidence levels in nurse leaders based upon an ethical decision-making framework.

Aims

The objective of this research was to compare ethical decision-making among nurse leaders in the U.S. and three German-speaking countries in Europe by developing and testing a newly constructed Ethical Decision-Making Confidence (EDMC) scale.

Methods

The cross-sectional survey included 18 theory-derived questions on ethical decision-making confidence which were used to develop the scale.

Participants

A convenience sample of nurse leaders from the U.S. and three German-speaking countries in Europe who self-identified as holding a leadership position.

Ethical Considerations

Ethical approval was given by the IRB Board of a U.S. university. Participation in the survey implied voluntary consent.

Results

The scale’s item structure dimensionality and subscale’s reliability were analyzed and compared between nurse leaders from all four countries. A principal component analysis (PCA) produced a 15-item bi-dimensional EDMC scale yielding a skill-related (9-item) and a behavior-related (6-item) confidence dimension. EDMC subscales showed good-to-excellent internal consistency. In both subscales, U.S. nurse leaders rated their mean EDMC score higher than their German-speaking counterparts in Europe.

Discussion

This exploratory study is the first of its kind to focus on nurse leaders’ confidence regarding ethical decision-making in an international context. An overarching factor structure was identified, which is shared by the two samples of nurse leaders and to examine (sub)scales’ psychometric properties.

Conclusion

This newly developed scale is an effective tool for measuring ethical decision-making confidence in nurse leaders. The promising results of this study should be replicated to ensure validity and reliability of the EDMC scale measuring skill-related and behavior-related concepts and include nurse leaders from various cultural, social, and demographic groups.

Moral distress interventions: An integrative literature review

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

A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19

Ethical dilemmas for healthcare workers (HCWs) during pandemics highlight the centrality of moral stressors and moral distress (MD) as well as potentially morally injurious events (PMIEs) and moral injury (MI). These constructs offer a novel approach to understanding workplace stressors in healthcare settings, especially in the demanding times of COVID-19, but they so far lack clear identification of causes and consequences. A scoping review of moral stressors, moral distress, PMIEs, and MI of healthcare workers during COVID-19 was conducted using the databases Web of Science Core Collection and PsycINFO based on articles published up to October 2021. Studies were selected based on the following inclusion criteria: (1) the measurement of either moral stress, MD, PMIEs, or MI among HCWs; (2) original research using qualitative or quantitative methods; and (3) the availability of the peer-reviewed original article in English or German. The initial search revealed n = 149,394 studies from Web of Science and n = 34 studies from EBSCOhost. Nineteen studies were included in the review. Conditions representing moral stressors and PMIEs as well as MD and MI as their potential outcomes in healthcare contexts during COVID-19 are presented and discussed. Highlighting MD and MI in HCWs during COVID-19 brings attention to the need for conceptualizing the impact of moral stressors of any degree. Therefore, the development of a common, theoretically founded model of MD and MI is desirable.

An evaluation of moral distress among healthcare workers during COVID-19 pandemic in Palestine

BACKGROUND

Moral distress among healthcare workers (HCWs) is considered a serious issue in all aspects of healthcare divisions, which needs an urgent intervention.

AIMS

The study aims at evaluating moral distress among HCWs which will help the healthcare management and decision-makers in hospitals and health centers to act in a comprehensiveness and effective way by reinforcing moral thinking and behavior in selected coronavirus (COVID-19) quarantine centers across Palestine.

METHODS

Ninety-four HCWs were selected by convenience sampling method. Data were collected using revised Corley's Standard Moral Distress (MD) Scale and analyzed using SPSS software version 23.

RESULTS

The mean score of MD for HCWs was low (1.24 ± 0.71). The mean score of MD severity was moderate (1.4 ± 0.93). The severity and frequency of MD in HCWs had a significant reverse relationship with years of experience, number of children of worker, and duration of work with COVID-19 patients.

CONCLUSION

It is important to create a professional psychological support system for HCWs to decrease MD when facing moral issues.