The Moral Distress-Appraisal Scale: Scale development and validation study

Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis

Investigations about moral resilience and moral courage as mediators between moral distress and moral injury remain underreported among nurses during the COVID-19 pandemic. Nurses (n = 412) from the Philippines were conveniently recruited via social media platforms and completed four self-report scales. The mediation model depicts that moral distress negatively impacts moral resilience and moral courage while positively affecting moral injury. Moral resilience and moral courage negatively impact moral injury, whereas moral resilience directly impacts moral courage. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. Findings indicate that healthcare organizations and nurse managers should nurture morally resilient and courageous therapeutic practices among frontline healthcare professionals to mitigate the negative effects of moral distress and moral injury.

Psychometric properties of the Turkish version of the moral distress-appraisal scale for nurses

Moral distress causes frustration, guilt, anger, stress, sadness, anxiety, fear, burnout, insecurity, and depression in nurses, and this is reflected in their work performances. Therefore, internationally validated tools and methodological studies are needed to measure moral distress among nurses. This study aims to evaluate the psychometric properties of the Turkish version of the Moral Distress-Appraisal Scale (MD-APPS) among nurses in Turkey. Psychometric properties of the Turkish version of the Moral Distress-Appraisal Scale (MD-APPS), which included internal consistency reliability and construct validity with factor analysis, were examined in a sample of 420 nurses working in different hospitals in Turkey completed the study between February and July 2022. The content validity index of the Turkish version of the MD-APPS based on expert opinions was 0.90. Through exploratory factor analysis for construct validity, a two-factor structure was obtained as in the original scale. The variance explained by these two factors was 56.67 %. Confirmatory factor analysis showed that the scale was valid, while internal consistency coefficient and test-retest results demonstrated that the scale was reliable. The Turkish version of the MD-APPS is a valid and reliable tool for evaluating moral distress among nurses.

A new approach to stress of conscience's dimensionality: Hindrance and violation stressors and their role in experiencing burnout and turnover intentions in healthcare

AIMS

To identify a valid, longitudinally invariant factor model for stress of conscience and to investigate how stress of conscience dimensions associate with burnout and turnover intentions.

BACKGROUND

There has been a lack of consensus about the number and content of stress of conscience dimensions, and a lack of longitudinal studies on its development and outcomes.

DESIGN

A longitudinal, person-centred survey study using the STROBE checklist.

METHODS

Healthcare personnel (n = 306) rated their stress of conscience in 2019 and 2021. Longitudinal latent profile analysis was used to identify different subgroups based on the employees' experiences. These subgroups were then compared in terms of burnout and organisational/professional turnover.

RESULTS

Five subgroups were identified, where participants experienced: (1) hindrance-related stress (14%), (2) violation-related stress (2%), (3) both stress dimensions increasing over time (13%), (4) both high yet decreasing over time (7%), and (5) stable levels of low stress (64%). When both hindrance- and violated-related stress were high, it was a significant risk for burnout and turnover. Shortened, 6-item, two-dimensional scale for stress of conscience was found to be reliable, valid, and longitudinally invariant.

CONCLUSION

On its own, hindrance-related stress (e.g. lowering one's aspirations for high-quality work) is less detrimental to well-being than when it is combined with violation-related stress (e.g. being forced to do something that feels wrong).

IMPLICATIONS FOR THE PROFESSION PATIENT CARE

To prevent burnout and staff turnover in healthcare, different risk factors for stress of conscience need to be identified and addressed.

PUBLIC CONTRIBUTION

Data were collected among public sector healthcare workers.

RELEVANCE TO CLINICAL PRACTICE

If healthcare workers are forced to ignore their personal values at work, it poses a significant risk for their well-being and retention.

The mediating roles of moral courage and moral resilience between nurses' moral distress and moral injury: An online cross-sectional study

AIMS

To investigate the mediating role of moral resilience and moral courage in the association between moral distress and moral injury.

BACKGROUND

There is a preponderance of nursing literature about moral distress, moral resilience, moral courage and moral injury. However, examining moral resilience and moral courage as mediators remain underreported during the COVID-19 pandemic and in the context of a developing nation.

DESIGN

Correlational, cross-sectional design compliant with the STROBE guidelines.

METHODS

A convenience sample of nurses (n = 412) from the Philippines were recruited using social media platforms (e.g., Facebook, Messenger, Twitter). Four self-report and validated scales (8-item Moral-Distress Appraisal Scale, 21-item Nurses' Moral Courage Scale, 17-item Rushton Moral Resilience Scale and 10-item Moral Injury Symptom Scale: Healthcare Professionals Version) were used to collect data from January to July 2022. Pearson's r, bivariate analysis and multistage regression analyses were used for data analysis.

RESULTS

This study afforded a model that depicted the interrelationships of moral distress, moral resilience, moral courage and moral injury. Moral distress has a negative impact on moral resilience and moral courage while positively affecting moral injury. Moral resilience positively influences moral courage while having a negative impact on moral injury. Moral courage has an indirect impact on moral injury. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury.

CONCLUSIONS

Healthcare organizations, policymakers and nurse managers should include policies and programs that include improving approaches to modifying workplace conditions and evaluating nurses' moral resilience and courage. Nurse managers need to advocate ethics education and professionalism. Nurses must practice self-care strategies to strengthen morally resilient and courageous therapeutic practices.

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.

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.