Moral Distress and Considering Leaving in NICU Nurses: Direct Effects and Indirect Effects Mediated by Burnout and the Hospital Ethical Climate

Overestimating prevalence? Rethinking boundaries and confounders of moral distress

Moral distress denotes a negative reaction to a morally challenging situation. It has been associated with adverse outcomes for healthcare professionals, patients and healthcare institutions. We argue that existing definitions, along with measures of moral distress, compromise the validity of empirical research. First, the definition and measurement of moral distress conflate moral events and psychological distress, even though they are distinct phenomena that should be assessed independently. Second, in many studies, there is a lack of clarity in distinguishing between moral and non-moral events. Finally, prior research on moral distress often overlooks the substantial body of evidence demonstrating the impact of diverse work-related factors, beyond moral events, on both distress and job retention. These challenges might undermine the effectiveness of interventions aimed at alleviating moral distress. We outline a comprehensive research agenda that encompasses conceptual clarifications, the refinement of data collection instruments, the design of studies and the application of appropriate statistical methods.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Ethical Climate in the Delivery Wards of Educational Hospitals in Southeast Iran

Ethical climate is one of the important factors in the working climate of the hospital. Considering the difference in the Ethical climate in different departments of the hospital and the importance of the ethical climate in the delivery ward, this study aimed to assess the characteristics of hospital ethical climate in delivery ward of educational hospitals in southeast Iran. This descriptive and multi-center study was conducted from 2020 to 2021 in educational hospitals in southeast Iran. Two hundred forty midwives working in delivery wards, midwifery instructors, and midwifery students were included in the study by census method. Data collection tools included a demographic information form, Olson's Hospital Ethical Climate Survey, completed using the self-report method. The mean ethical climate in the midwifery group (3.82 ± 0.63 out of 5) was higher than in the instructors' and students' groups. The lowest mean score obtained from the ethical climate questionnaire of participants was associated with the inability to use their experiences in the delivery ward. The lowest mean of ethical climate from the midwives' point of view is the Physicians' dimension and the patient's dimension from the instructors' point of view. The highest mean score belonged to the ethical climate of the supervisors. According to the results of the present study, it is suggested to implement protective laws to support the higher independence of midwives to improve the ethical climates by using their experiences in the delivery department.

Anxiety prevalence and associated factors among frontline nurses following the COVID-19 pandemic: a large-scale cross-sectional study

Introduction

Nurses are more likely to experience anxiety following the coronavirus 2019 epidemic. Anxiety could compromise nurses' work efficiency and diminish their professional commitment. This study aims to investigate nurses' anxiety prevalence and related factors following the pandemic in multiple hospitals across China.

Methods

An online survey was conducted from April 16 to July 3, 2023, targeting frontline nurses who had actively participated in China. Anxiety and depression symptoms were assessed using the Self-rating Anxiety Scale and the Self-rating Depression Scale (SDS), respectively. Multivariable logistic regression analysis was employed to identify factors linked with anxiety.

Results

A total of 2,210 frontline nurses participated in the study. Overall, 65.07% of participants displayed clinically significant anxiety symptoms. Multivariable logistic regression revealed that nurses living with their families [2.52(95% CI: 1.68-3.77)] and those with higher SDS scores [1.26(95% CI: 1.24-1.29)] faced an elevated risk of anxiety. Conversely, female nurses [0.02(95% CI: 0.00-0.90)] and those who had recovered from infection [0.05(95%CI: 0.07-0.18)] demonstrated lower rates of anxiety.

Discussion

This study highlights the association between SDS score, gender, virus infection, living arrangements and anxiety. Frontline nurses need to be provided with emotional support to prevent anxiety. These insights can guide interventions to protect the mental well-being of frontline nurses in the post-pandemic period.

The relationship between alarm fatigue and burnout among critical care nurses: A cross-sectional study

BACKGROUND

Alarm fatigue has significant negative impacts on nurses and patient safety. However, the relationship between alarm fatigue and burnout is still unclear.

AIMS

This study aimed to explore the relationship between alarm fatigue and burnout among critical care nurses.

STUDY DESIGN

A descriptive-analytical cross-sectional study design was used. Data were collected from five hospitals in mainland China between January 2022 and March 2022. A general information questionnaire, the Chinese version of the Intensive Care Unit Nurse Alarm Fatigue Questionnaire, and the Chinese version of the Maslach Burnout Inventory were used.

RESULTS

A total of 236 critical care nurses were enrolled in this study. The mean score of alarm fatigue among critical care nurses was 21.11 ± 6.83. The results showed that critical care nurses experienced moderate alarm fatigue levels, and most nurses had moderate to high levels of burnout. The multiple linear regression analyses showed that alarm fatigue was independently associated with emotional exhaustion, depersonalization dimensions, and reduced personal accomplishment dimension.

CONCLUSIONS

Alarm fatigue was associated with burnout among critical care nurses. Reducing critical care nurses' alarm fatigue may help to alleviate burnout.

RELEVANCE TO CLINICAL PRACTICE

Managers should provide comprehensive training for nurses and promote the application of artificial intelligence technology in alarm management to reduce alarm fatigue and improve burnout among critical care nurses.

Ethical climate in healthcare: A systematic review and meta-analysis

BACKGROUND

Ethical climate refers to the shared perception of ethical norms and sets the scope for what is ethical and acceptable behaviour within teams.

AIM

This paper sought to explore perceptions of ethical climate amongst healthcare workers as measured by the Ethical Climate Questionnaire (ECQ), the Hospital Ethical Climate Survey (HECS) and the Ethics Environment Questionnaire (EEQ).

METHODS

A systematic review and meta-analysis was utilised. PSYCINFO, CINAHL, WEB OF SCIENCE, MEDLINE and EMBASE were searched, and papers were included if they sampled healthcare workers and used the ECQ, HECS or EEQ.

ETHICAL CONSIDERATION

Ethical approval was not required.

RESULTS

The search returned 1020 results. After screening, 61 papers were included (n = 43 HECS, n = 15 ECQ, n = 3 EEQ). The overall sample size was over 17,000. The pooled mean score for the HECS was 3.60. Mean scores of individual studies ranged from 2.97 to 4.5. For the HECS studies, meta-regression was carried out. No relationship was found between the country of the studies, the study setting (ICU v non-ICU settings) or the mean years of experience that the sample had. For the ECQ, sub-scales had mean scores ranging from 3.41 (instrumental) to 4.34 (law) and were all observed to have significant and substantial heterogeneity. Three studies utilised the EEQ so further analysis was not carried out.

CONCLUSIONS

The above results provide insight into the variability of scores as measured by the HECS, ECQ and EEQ. To some extent, this variability is not surprising with studies carried out across 21 countries and in a range of healthcare systems. Results also suggest that it may be that more local and context specific factors are more important when it comes to predicting ethical climate.

Estimation of moral distress among nurses: A systematic review and meta-analysis

BACKGROUND

Moral distress is a common challenge among professional nurses when caring for their patients, especially when they need to make rapid decisions. Therefore, leaving moral distress unconsidered may jeopardize patient quality of care, safety, and satisfaction.

AIM

To estimate moral distress among nurses.

METHODS

This systematic review and meta-analysis conducted systematic search in Scopus, PubMed, ProQuest, ISI Web of Knowledge, and PsycInfo up to end of February 2022. Methodological quality of included studies was assessed using the Newcastle Ottawa checklist. Data from included studies were pooled by meta-analysis with random effect model in STATA software version 14. The selected key measure was mean score of moral distress total score with its' 95% Confidence Interval was reported. Subgroup analyses and meta-regressions were conducted to identify possible sources of heterogeneity and potentially influencing variables on moral distress. Funnel plots and Begg's Tests were used to assess publication bias. The Jackknife method was used for sensitivity analysis.

ETHICAL CONSIDERATION

The protocol of this project was registered in the PROSPERO database under decree code of CRD42021267773.

RESULTS

Eighty-six manuscripts with 19,537 participants from 21 countries were included. The pooled estimated mean score of moral distress was 2.55 on a 0-10 scale [95% Confidence Interval: 2.27-2.84, I²: 98.4%, Tau²:0.94]. Publication bias and small study effect was ruled out. Moral distress significantly decreased in the COVID-19 pandemic versus before. Nurses working in developing countries experienced higher level of moral distress compared to their counterparts in developed countries. Nurses' workplace (e.g., hospital ward) was not linked to severity of moral disturbance.

CONCLUSION

The results of the study showed a low level of pooled estimated score for moral distress. Although the score of moral distress was not high, nurses working in developing countries reported higher levels of moral distress than those working in developed countries. Therefore, it is necessary that future studies focus on creating a supportive environment in hospitals and medical centers for nurses to reduce moral distress and improve healthcare.

Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy

Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.

Ethical Considerations for Equitable Access to Genomic Sequencing for Critically Ill Neonates in the United States

Rare diseases impact all socio-economic, geographic, and racial groups indiscriminately. Newborn screening (NBS) is an exemplary international public health initiative that identifies infants with rare conditions early in life to reduce morbidity and mortality. NBS theoretically promotes equity through universal access, regardless of financial ability. There is however heterogeneity in access to newborn screening and conditions that are screened throughout the world. In the United States and some other developed countries, NBS is provided to all babies, subsidized by the local or federal government. Although NBS is an equitable test, infants admitted to neonatal intensive care units (NICUs) may not receive similar benefits to healthier infants. Newborns in the NICU may receive delayed and/or multiple newborn screens due to known limitations in interpreting the results with prematurity, total parenteral nutrition, blood transfusions, infection, and life support. Thus, genomic technologies might be needed in addition to NBS for equitable care of this vulnerable population. Whole exome (WES) and genome sequencing (WGS) have been recently studied in critically ill newborns across the world and have shown promising results in shortening diagnostic odysseys and providing clinical utility. However, in certain circumstances several barriers might limit access to these tests. Here, we discuss some of the existing barriers to genomic sequencing in NICUs in the United States, explore the ethical implications related to low access, consider ways to increase access to genomic testing, and offer some suggestions for future research in these areas.

Burnout and Turnover among NICU Nurses

INTRODUCTION

In 2019, the national average turnover rate of registered nurses in the United States was approximately 17.8%. Each percentage increase in turnover costs a hospital, on average, $270,800. Although burnout is a known contributor to nurses' turnover intention, few studies have examined the relationship between nurse burnout and turnover, and there is little data on this relationship in neonatal intensive care environments. The purpose of this study was to examine the relationship between nurse burnout and turnover among neonatal intensive care unit (NICU) nurses.

STUDY DESIGN

A secondary analysis of data collected from an observational study involving 136 nurses in a 52-bed NICU from 2013 to 2014.

METHODS

Multivariate logistic regression models were used to test for associations between measures of burnout and turnover.

RESULTS

16.9% of nurses turned over during the 11 months of the original study. Most nurses reported high (46%) to moderate (37%) levels of emotional exhaustion. Final models did not indicate a relationship between burnout and turnover.

CLINICAL NURSING IMPLICATIONS

Although burnout has been associated with turnover intent among nurses, we did not observe an association between burnout and turnover among NICU nurses. Despite no direct relationship between burnout and turnover in the NICU, burnout may have other negative consequences. Nurse leaders should continue to prioritize reducing burnout among nursing staff to improve the well-being of the NICU nurse workforce.

Dimensions of the Burnout Measure: Relationships with shame- and guilt-proneness in neonatal intensive care unit nurses

BACKGROUND

Burnout in neonatal intensive care unit (NICU) nurses has been correlated with personality proneness to shame. However, the structural validities of the one-factor Burnout Measure (BM) and the two-factor Personal Feelings Questionnaire-2 (PFQ-2) used to assess burnout and shame-proneness, respectively, in these nurses were not evaluated.

OBJECTIVES

The aim of the study was (i) to perform factor analyses of the BM and the PFQ-2 and (ii) to determine the relationships of burnout dimensions retrieved by factor analysis with similarly validated dimensions of shame- and guilt-proneness in NICU nurses.

METHODS

This is a multicentre cross-sectional cohort study that involved 142 (24%) of 585 NICU nurses who were currently providing direct newborn care in six level 3-4 NICUs in New South Wales, Australia.

RESULTS

The BM was a multidimensional measure of burnout composed of three latent factors: Demoralisation, exhaustion, and loss of motive. Based on burnout dimension mean scores of 4 or more, worryingly high levels of Demoralisation, Exhaustion, and Loss of Motive were reported by 21%, 84%, and 24% of nurses, respectively. Shame and Guilt together explained 41%, 9%, and 15% of the variance in Demoralisation, Exhaustion, and Loss of Motive, respectively. Shame controlled for guilt made respective large and moderate contributions to the variance in Demoralisation (β = .62, p < .001) and Loss of Motive (β = .33, p < .001). Guilt moderated the effect of Shame on Loss of Motive (ΔR² = .031, p = .027).

CONCLUSIONS

Factor analysis of the BM showed burnout in NICU nurses was a multidimensional syndrome comprising exhaustion, Demoralisation, and loss of motive. Worryingly high levels of exhaustion, Demoralisation, and loss of motive were not uncommon. The Demoralisation dimension had a strong correlation with shame-proneness. Understanding the nature of Demoralisation and the phenomenology of shame and guilt should be psychoeducational components of the holistic management of burnout in NICU nurses.