Psychometric validation of the Persian version of the ethical awareness scale for nurses working in Iranian intensive care units

AIM

The purpose of this study was to translate and validate the ethical awareness scale for nurses working in Iranian intensive care units.

DESIGN

A cross-sectional psychometric study.

METHODS

The study was conducted in Oct 2020 to Sep 2021, involving the participation of 200 ICU nurses. The process included translation of the original version of the ethical awareness scale into Persian, following the World Health Organization guideline, for use in Iran. The translated version was then evaluated for reliability, face validity, content validity ratio, content validity index, convergent validity and construct validity.

RESULTS

The initial reliability of the scale was established. In qualitative face validity, a few items changed slightly and all items were retained in the quantitative face validity assessment. Based on Lawshe's values, three items were removed from the scale during CVR assessment. All items exhibited acceptable CVI scores. Convergent validity was established with an average variance extracted greater than 0.5. The fit indices, such as CFI = 0.94, GFI = 0.94, RMSEA = 0.01, AGFI = 0.97 and CMIN/DF = 2.99, supported the structural model of the scale. The fit indices for the structural model of the scale were all within acceptable ranges, suggesting that the model fit the data well. Its reliability was confirmed through the test-retest method, with Cronbach's alpha = 0.84 and McDonald's omega coefficient >0.8.

CONCLUSION

The findings of this study indicate the Persian version of the ethical awareness scale for Iran (EAS-IR) is comparable in content to the original version, demonstrating its validity and reliability for assessing ethical awareness among Iranian nurses in ICUs. The scale can be a valuable resource for measuring ethical awareness in the Iranian healthcare context and may contribute to improving ethical practices and decision-making in ICU settings.

PATIENT OR PUBLIC CONTRIBUTION

In this project, no patient or public contribution was necessary, because it was not applied to our work.

Nurses' moral courage and related factors: A systematic review

BACKGROUND

Nurses face various ethical conflicts when taking care of patients, and such conflicts require moral courage. This systematic review was conducted with the aim of investigating moral courage and its related factors among nurses.

METHODS

To find related studies, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The PubMed, Web of Science, Google Scholar, Scopus, Embase and Science Direct databases were searched using keywords such as Courage, Moral Courage, and Nurses, and no lower time limit was imposed when conducting the searches. The identified studies were published between January 2000 and March 2023. Quality of articles was assessed using the STROBE checklist.

RESULTS

The pooled sample size for the 19 included studies was 7863. All studies were observational and cross-sectional. The results showed that three categories of factors most related to moral courage are individual, moral, and factors related to the organization. Underlying factors of each category are also provided within this paper.

CONCLUSION

Moral courage is an integral part of nursing, which as a profession, is becoming even more challenging with the advancement of science and technology. Therefore, there is a need for nurses and especially nursing managers to be considerate of factors affecting moral courage of nurses, with a view to strengthening the positive factors and reducing the negative impacts.

Moral distress in nurses in developing economies: an integrative literature review

Background

Moral distress has been extensively studied in developed economies; however, not much in terms of studies has been carried out in developing economies.

Objective

To review the literature reporting the experience of moral distress in nurses in health care settings in developing economies.

Design

An integrative literataure review was used.

Method

Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online Cochrane and Psych INFO were searched to retrieve titles and abstracts of papers on the experience of moral distress in nurses in developing economies.

Results

Sixteen articles reporting the experience of moral distress in nurses in developing economies published between 1984 and March 2019 were used for the review. Analysis of the findings revealed seven themes, nurses' experience of moral distress, inadequate material and human resources, end-of-life challenges, cultural and religious beliefs as a source of moral distress, perceived inactions of medical and nursing staff, impact of moral distress on nurses in developing economies and coping strategies.

Conclusion

There is paucity of empirical studies on moral distress in nurses in developing economies. More qualitative studies are needed in various cultural settings to enhance its understanding in nurses working in developing economies.

Examining the effect of moral resilience on moral distress

AIMS

The study aims to test the Turkish validity and reliability of the Rushton Moral Resilience Scale (RMRS) and examine the effect of moral resilience on moral distress.

BACKGROUND

Moral distress is a phenomenon that negatively affects health workers, health institutions, and the person receiving care. In order to eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience involves developing systems that support a culture of ethical practice in healthcare and aim to increase an individual's capacity to cope with moral challenges.

METHODS

A methodological and descriptive-predictive study design was adopted. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals (MMD-HP), and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 255 clinical nurses were recruited.

ETHICAL CONSIDERATIONS

Hacettepe University's non-interventional ethics committee approved the study's protocol and informed consent was obtained from the participants.

RESULTS

The original four-factor structure of the scale was tested with confirmatory factor analysis, and the index values were evaluated and found at an acceptable level. The Cronbach Alpha coefficient of the scale was found to be 0.826. Moral resilience predicted moral distress total, intensity, and frequency levels. A moderate and weak relationship was found in the negative between all sub-dimensions of moral distress and moral resilience.

CONCLUSIONS

The Rushton Moral Resilience Scale Turkish version showed good psychometric properties. Moral resilience has a reducing effect on moral distress. Young nurses who have less experience are at risk because they have lower moral resilience levels, while nurses working in intensive care units are at risk because of their high moral distress levels. A healthy workplace can be created by developing specific approaches to improve moral resilience in reducing the impact of moral distress in the healthcare environment.

Turkish Adaptation of the Moral Distress Scale-Revised for Pediatric Nurses: A Validity and Reliability Study

Background and Purpose: Recent studies have demonstrated the adverse effects that moral distress experienced by nurses has on nurses, patients, and the healthcare system. This study aims to analyze the validity and reliability of the Turkish version of the Moral Distress Scale-Revised (MDS-R, pediatric). Methods: This study was conducted with 210 pediatric nurses. Results: Explanatory factor analysis was conducted, and a five-factor structure emerged. The Cronbach's α value of the scale was found to be 0.865, and the correlation-based item analysis showed that the values were within the acceptable range, and the discrimination of the items was adequate. Conclusions: Analyses conducted revealed that the Turkish version of the MDS-R (pediatric), consisting of 21 items and five subdimensions, is a valid and reliable measurement tool for the Turkish culture and language.

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed-methods systematic review and thematic synthesis

AIM

To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well-being and professional and career intentions.

DESIGN

Joanna Briggs Institute mixed-methods systematic review and thematic synthesis. Registered in Prospero (Redacted).

METHODS

Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction.

RESULTS

Searches yielded 2343 hits. Seventy-seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well-being.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: a clinical randomized controlled trial

BACKGROUND

Ethical decision‑making and behavior of nurses are major factors that can affect the quality of nursing care. Moral development of nurses to making better ethical decision-making is an essential element for managing the care process. The main aim of this study was to examine and comparison the effect of training in ethical decision-making through lectures and group discussions on nurses' moral reasoning, moral distress and moral sensitivity.

METHODS

In this randomized clinical trial study with a pre- and post-test design, 66 nurses with moral reasoning scores lower than the average of the community were randomly assigned into three equal groups (n = 22) including two experimental groups and one control group. Ethical decision-making training to experimental groups was provided through the lectures and group discussions. While, the control group did not receive any training. Data were collected using sociodemographic questionnaire, the nursing dilemma test (NDT), the moral distress scale (MDS) and the moral sensitivity questionnaire (MSQ). Unadjusted and adjusted binary logistic regression analysis was reported using the odds ratio (OR) and 95% confidence intervals.

RESULTS

Adjusted regression analysis showed that the probability of increasing the nursing principle thinking (NPT) score through discussion training was significantly higher than lecture (OR: 13.078, 95% CI: 3.238-15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171-2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15-5.834, P < 0.001). The possibility of increasing moral sensitivity score through discussion training was significantly higher than lecture (OR: 10.874, 95%CI: 6.043-12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454-16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no significant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015-0.717, P = 0.021) and discussion group vs. control group (OR: 0.089, 95% CI: 0.015-0.547, P = 0.009).

CONCLUSIONS

The results of this study indicate that ethical decision-making training is effective on empowerment of ethical reasoning. Whereas the group discussion was also effective on increasing the ethical sensitivity, it is recommended the training plan provided in this study to be held as workshop for all nurses in health and treatment centers and placed in curricular plan of nursing students.

REGISTRATION

This randomized clinical trial was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.

An educational program of reducing moral distress (PRMD) in nurses; designing and evaluating

BACKGROUND

Moral distress is common phenomenon that has negative consequences on nurses, patients, and healthcare systems. This study aims to design and evaluate an educational program to reduce moral distress in nurses.

METHODS

This multiphase mixed-method study was done in three stage on February 2021 in Shiraz/Iran. In pre-implementation stage, a content analysis study was conducted on 12 participants were interviewed using purposive sampling and then the program was designed according to qualitative data, panel of expertise and literature review according the seven steps of Ewles and Sminett's model and implemented in one group on 40 nurses using a quasi-experimental design. In Post-Implementation stage, effectiveness of program was evaluated through quantitative and qualitative methods. Quantitative data were gathered by Hamric's 21-question moral distress questionnaire analyzed via SPSS v.25 and analysis of variance repeated measures test. Also, a content analysis study was conducted on 6 PRMD participants using purposive sampling. In Program evaluation stage, convergence of quantitative and qualitative data and the effects of the program were examined. Trustworthiness of qualitative data was accomplished by Lincoln and Guba criteria.

RESULTS

First quantitative study revealed the causes of moral distress consisted of deficiency in professional competency, unsuitable organizational culture, personal factors, environmental and organizational factors, management factors, insufficiencies in proficient and efficient communication and nurses' observation of moral dilemma. Results of quantitative stage showed that there was a significant difference (p < 0.05) between the mean score of moral distress before, after, 1 and 2 months after the intervention. The participants in secondary qualitative stage, reported increasing their moral knowledge and skills, improving ethical climate, and moral empowerment.

CONCLUSION

The use of different educational tools and teaching methods and the participation of managers in designing strategies had a very effective role in the effectiveness of this educational program.

A Systematic Review and Meta-analytic Evaluation of Moral Distress in Oncology Nursing

BACKGROUND

Weighing implications of multiple intensive cancer-directed therapies over time, oncology nurses are more prone to intrinsic distress compared to nurses in non-oncologic settings. This vulnerability may give rise to moral distress. Yet, little is known about moral distress experiences of oncology nurses.

OBJECTIVE

This systematic review and meta-analysis examined the frequency and intensity of moral distress among oncology nurses with an exploratory focus on nurse-level and work-related characteristics.

METHODS

We conducted a systematic search of 7 electronic databases (2000-2020) supplemented by hand-search strategy. Means and standard deviations of moral distress scores in the included studies were extracted and pooled in our meta-analysis.

RESULTS

Our sample of 8 cross-sectional studies consisting of 2686 participants with 1654 oncology nurses met criteria for inclusion. A random-effects model was used in our meta-analysis given considerable heterogeneity. Our results suggest that moral distress was of low to moderate frequency, but of high intensity. Moral distress among oncology nurses was a significant predictor for burnout, provider communication, decisions surrounding end-of-life care, work conditions (eg, patient assignment, type of unit), and inability to provide compassionate care.

CONCLUSION

Moral distress in oncology nurses is associated with burnout syndrome, compassion fatigue, and secondary traumatic stress syndrome, all of which are linked to poor patient care and outcomes. Robust psychological well-being is critical in minimizing unintended consequences of moral distress.

IMPLICATIONS FOR PRACTICE

Oncology nurses are at high risk for moral distress due to the nature of their work. Future studies should examine the prevalence among oncology nurses to help inform targeted interventions.

NICU nurses' moral distress surrounding the deaths of infants

BACKGROUND

As Korean neonatal nurses frequently experience the deaths of infants, moral distress occurs when they provide end-of-life care to the infants and their families. Although they need to care for the patients' deaths and consequently experience burnout and turnover due to moral distress from the situation, there is a lack of a support for nurses. Moreover, not much information is available on the moral distress of neonatal nurses. There is a need to better understand Korean neonatal nurses' moral distress to develop and implement appropriate supports.

OBJECTIVE

This study aimed to describe nurses' experience of moral distress when they provide end-of-life care to infants and their families in neonatal intensive care units.

RESEARCH DESIGN

This is a secondary analysis qualitative study. Content analysis was performed based on Corley's theory of moral distress to develop a codebook and identify themes regarding moral distress among the nurses.

PARTICIPANTS AND RESEARCH CONTEXT

Qualitative data were collected from 20 nurses working in two NICUs in Seoul, South Korea.

ETHICAL CONSIDERATIONS

The original study obtained permission from a university's institutional review board (IRB). This secondary analysis study obtained the exemption from another university's IRB. Nurses' participation was voluntary and confidential.

FINDINGS

The nurses' moral distress was derived when they faced moral constraints and/or moral conflicts. Two distinct categories of moral constraints and four distinct categories of moral conflicts were identified among the neonatal nurses. In addition, impacts of moral distress on patients and nurses were identified.

CONCLUSIONS

This study identified occasions neonatal nurses experience moral distress, and thus can guide in developing and implementing effective interventions to decrease their moral distress and improve their resilience in end-of-life care by providing insight into neonatal nurses' needs for support in end-of-life care.

A Study of How Moral Courage and Moral Sensitivity Correlate with Safe Care in Special Care Nursing

Background

Nursing is a caring profession, and nurses who have moral sensitivity and moral courage presumably can provide safe and better care for patients. This study aims at investigating how moral courage and moral sensitivity correlate with safe care in special care nursing.

Methods

This study is a descriptive work of research. The participants consisted of 524 nurses who were in practice in the ICU (intensive care unit), CCU (C\coronary care unit), post-CCU (postcoronary care unit), and dialysis of four hospitals located in the south of Iran selected via census sampling. Data were collected from April to September 2020 using the moral sensitivity questionnaire (MSQ), professional moral courage questionnaire (PMCQ), and the assessment of safe nursing care questionnaire (ASNCQ). The collected data were analyzed using descriptive statistics, t-test, chi-square, multiple regression analysis, and Pearson's correlation coefficient in SPSS v. 22.

Results

The mean ± SD of the nurses' age was 33.89 ± 6.91 years, and the mean ± SD of their work experience was 9.16 ± 4.67 years. The total mean score ± SD of the nurses' moral sensitivity was found to be 93.41 ± 2.68, the total mean score ± SD of their moral courage was found to be 96.38 ± 3.63, and the total mean score ± SD of their safe care scores was found to be 321.80 ± 9.76. The values of Pearson's correlation coefficients showed significant correlations between moral courage and safe care (r = 0.54, p < 0.001), moral sensitivity and safe care (r = 0.59, p < 0.001), and moral sensitivity and moral courage (r = 0.52, p < 0.001).

Conclusion

There is a positive correlation between moral sensitivity and moral courage. Both positively correlated with special care nursing. Accordingly, through effective planning, education, and giving their support, nurse administrators can promote the abovementioned ethical virtues in the nursing staff, thereby improving the quality of care.

Culturally-sensitive moral distress experiences of intensive care nurses: A scoping review

BACKGROUND

Moral distress is a phenomenon that all nurses experience at different levels and contexts. The level of moral distress can be affected by individual values and the local culture. The sources of the values shape the level of moral distress experienced and the nurses' decisions.

AIM

The present scoping review was conducted to examine the situations that cause moral distress in ICU nurses in different countries.

RESULTS

A scoping review methodology was adopted for the study, in line with the approach of Arksey, and O'Malley Literature was searched within PubMed/Medline, Scopus, Web of Science, and PsycINFO indexed keywords such as "moral distress", "Critical Care Nurse", and "Moral Distress Scale-Revised". Of the 617 identified citations, 12 articles matched the inclusion criteria.

CONCLUSION

The moral distress experienced in countries and regions with similar cultures and geographies was parallel. The situations that cause the most moral distress are futile-care to prolong death, unnecessary tests and treatments, and working with incompetent healthcare personnel.

The Effect on the Care Behaviors of Nurses Working in Intensive Care Clinics of Moral Distress Experienced During End of Life Patient Care

This research was conducted as a descriptive study in order to examine the effects of the moral problems experienced by nurses working in intensive care clinics on their end of life care behaviors. The data were collected using the Moral Distress Scale and Caring Behaviors Inventory. It was found that 74.5% of the nurses were women and their mean age was 32.60 ± 6.6 years. The frequency of moral distress in the nurses was 44.27 ± 16.25 and total score was 111.02 ± 63.85. There were significant differences in the scores of the concept the use of futile treatment by nurses, the decision not to begin life-support treatment being made only by physicians, and moral distress and discomfort felt by pediatric intensive care nurses (p < .05). A statistically significant relationship was found between total scores of discomfort on moral distress and assurance, knowledge and skills, connectedness, and being respectful on the end of life care behaviors (p < .05).

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Moral Sensitivity and Emotional Intelligence in Intensive Care Unit Nurses

Moral sensitivity helps individuals resolve moral dilemmas as a precursor to moral decision-making. Intensive care unit (ICU) nurses are at high risk for encountering moral dilemmas and should have the moral sensitivity to recognize moral issues. The activities of ICU nurses in moral decision-making are guided by moral sensitivity but are also based on emotional intelligence (EI). EI, be recognized as an integral part of moral sensitivity with long-standing theoretical foundations. It is necessary to explicate the true role of EI in moral sensitivity through empirical research. To measure the level of moral sensitivity of ICU nurses and determine the relationship between moral sensitivity and EI. We recruited 467 ICU nurses of ten hospitals from March to June 2021 in Hunan Province, China for a cross-sectional questionnaire survey. The moral sensitivity and EI were measured using the Moral Sensitivity Questionnaire-Revised Version into Chinese (MSQ-R-CV) and the Wong and Law Emotional Intelligence Scale-Version into Chinese (WLEIS-C). A self-report questionnaire covered sociodemographic characteristics. The average moral sensitivity score of ICU nurses was 39.41 ± 7.21. The average EI score was significantly positively correlated with the moral sensitivity score (p < 0.001). This study demonstrated that the moral sensitivities of ICU nurses were at medium levels. EI of ICU nurses can indeed affect their moral sensitivity, and the impact of each element of EI should be clarified for practical application.

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.

How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study

OBJECTIVE

To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents.

METHODS

We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains.

RESULTS

We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief.

CONCLUSIONS

We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.

Psychometrics of the moral distress scale in Iranian mental health nurses

BACKGROUND

One of the challenges that nurses often face in ethical decision-making situations is moral distress. Moral distress is caused by the conflict between professional and individual values in decision-making situations. Despite its importance, there is no reliable scale in Persian to measure it. Therefore, this study was conducted to validate the moral distress scale in mental health nurses in Iranian culture and Persian language.

METHODS

This study was conducted in two parts: Translation and cross-cultural adaptation and psychometric analysis. The translation and cross-cultural adaptation process was conducted based on the Polit approach. Next, face validity (qualitative), content validity (quantitative and qualitative), and construct validity were examined. This part of the study was a cross-sectional study. In this step, a demographic questionnaire and the Moral Distress Scale were sent to 500 nurses working in selected educational and medical centers in Iran via online questionnaires. Then, the construct validity of the "Moral Distress Scale" was confirmed by confirmatory factor analysis and the reliability of the instrument was examined by studying the internal consistency with Cronbach's alpha and the internal correlation of the AIC.

RESULTS

The confirmatory factor analysis showed an acceptable ratio of the expressions in 15 items in three factors: Acquiescence to patients' rights violations (6 items), Unethical conduct by caregivers (5 items), and low staffing (4 items) in the scale. The internal consistency of the instrument with Cronbach's alpha was higher than 7.0.

CONCLUSION

The Persian version of moral distress with 15 items of the three factors had validity and reliability. According to the present findings, this scale can be used to study moral distress among nurses working in psychiatric wards. Moral distress leads to burnout, increases risks to patient safety and reduces quality of care. Nurses need to be able to assess and manage moral distress. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. Considering that culture has an impact on nurses' moral distress, it is suggested that this instrument be studied in and tested in other languages and cultures.

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

Background

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

Methods

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

Results

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

Conclusions

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

A focused ethnography of the culture of inclusive caring practice in the intensive care unit

Aim

To explore and understand the culture of nurses' multidimensional “caring‐for” practice in intensive care unit (ICU).

Design

A focused ethnography.

Methods

Data were collected from 35 Registered Nurses through participant observations, field notes, documentation reviews, interviews, informal conversations and Participants' additional information forms over 6 months in one ICU. Thematic data analysis was used.

Findings

Different dimensions of nursing caring in ICU were found. The inclusivity of a culture of nurses' “caring‐for” involved the following: oneself, patients and their families, different colleagues, and caring as ecological consciousness in the ICU environment and organization.

Moral distress among nurses: A mixed-methods study

BACKGROUND

Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand.

OBJECTIVE

This study aims to describe the experience of moral distress and related factors among Thai nurses.

DESIGN

A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated.

PARTICIPANTS

Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand.

ETHICAL CONSIDERATIONS

This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151.

RESULTS

A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress.

DISCUSSION

Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient's and family's religious perspective that ties into the concept of moral distress needs to be explored.

CONCLUSIONS

Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context.

Moral distress and its contributing factors among emergency department nurses: A cross-sectional study in Iran

BACKGROUND

Moral Distress (MD) is a common experience in nursing practice and constitutes one of the main reasons for professional burnout, job withdrawal, fatigue, and avoidance of patient care among nurses. The causes, frequency and severity of MD vary according to the ward and hospital of service. The present study was conducted to determine the frequency and severity of MD and its contributing factors among Emergency Department (ED) nurses in Iran.

METHODS

This descriptive cross-sectional study was conducted in 2019.A total of 203 participants were selected by census sampling from the 248 nurses working in the EDs of hospitals in Semnan Province, Iran. Data were collected using Corley's Moral Distress Scale-Revised and analyzed using descriptive and inferential statistics.

FINDINGS

The mean severity and frequency of MD were 1.36 ± 0.74 and 1.20 ± 0.68 out of 4, respectively. The MD levels were significantly higher in female nurses (p = 0.002), those under 30 years of age (p = 0.003), with less than ten years' work experience (p = 0.03), and with higher levels of education (p < 0.001). In addition, inverse and significant relationships were found between MD and the nurses' age (r = -0.202,p = 0.004) and work experience(r = -0.149, p = 0.034).

CONCLUSION

According to the results, nurses had moderate levels of MD. Numerous factors, including age, gender, work experience, and education, were associated with the total MD score.To reduce MD and its negative effects on nurses, it is necessary to address these factors and appropriately plan to identify and manage MD so as to improve the quality of nursing care.

Ethical challenges of caring for burn patients: a qualitative study

Background

Burn patients are among the most vulnerable groups of patients requiring principled ethical care. Caring for these patients often brings various ethical challenges for the members of the health care teams, especially nurses, which affect the clinical decisions made for these patients. A limited number of studies have addressed the ethical challenges of caring for burn patients for the responsible caregivers, so the present study attempted to identify these challenges. The present study aimed to explore the health professionals' experiences of the ethical challenges during caring for burn patients.

Methods

This was a qualitative study with a descriptive, phenomenological design. 22 health professional practiced in public burn centers in Iran who met the inclusion criteria of the study were selected via purposeful sampling to participate in the study from June to August 2019. Data were collected using semi-structured, in-depth interviews with the individuals as well as field notes. Sampling was continued up to the data saturation. Thereafter, the collected data were analyzed using Colaizzi's method.

Results

The findings of the study yielded 3 themes, including respect for the patient's privacy, respect for the patient's personal identity, and care challenges, as well as 9 categories.

Conclusion

The findings of this study showed that the burn patients’ caregivers face some challenges in the domains of maintaining the patient's privacy, respecting the patient’s personal identity, and making the best clinical decision. Thus, providing the cultural, professional, and organizational requirements of meeting the challenges of caring for burn patients can consequently result in the caregivers’ inner peace and the improved performance.

The relationship between work-life balance, the need for achievement, and intention to leave: Mixed-method study

AIMS

To examine the mediating role of employee well-being on the relationship between work-life balance practices, the need for achievement and intention to leave among nurses in Malaysia.

BACKGROUND

Work-life balance practices are associated with employee perceptions of the need for achievement and well-being which subsequently influence their intention to leave the organization. This study contributes new knowledge to nursing studies on work-life balance in an Asian and Islamic society where the expectations for women are to focus on family rather than career.

DESIGN

A cross-sectional, explanatory mixed methodology.

METHODS

This is a two-phase study conducted between 2015-2017 with 401 nurses in East Malaysia. In Phase 1, researchers surveyed 379 nurses to test eight hypotheses and in Phase 2 researchers interviewed 22 nurses to explore the results of Phase 1.

RESULTS

Phase 1 revealed job satisfaction mediates the relationship between work-life balance practices (e.g. flexibility and choice in working hours, supportive supervision), financial success, and intention to leave. However, life satisfaction and money as a motivator did not mediate such relationships. Phase 2 identified four important factors that cast light on survey results: working conditions of Malaysian nurses; inadequate compensation in the public healthcare sector; team-based practices; and pressure on senior nurses in both administrative and clinical roles.

CONCLUSION

This is one of the first studies to investigate work-life balance issues among nurses in Malaysia. Outcomes of this study extend the debates on work-life balance and employee well-being in an Asian Islamic social context.

IMPACT

The use of flexible working arrangements and collectivist teamwork approaches, improving compensation and employment benefits and eliminating the 'time-based job promotion' policy may help to mitigate work-life balance issues and intention to leave among nurses in Malaysia.

The ethical dilemma of placebo use in clinical practice

The clinical use of placebo that involves some ethical issues has led to much controversy. From the standpoint of both supporters and opponents, this article discusses this topic from three ethical principles such as beneficence, justice, and autonomy and also gives the recommendations. Finally, the moral dilemma caused by the different views between nurses and doctors in clinical practice is discussed.

Health Professionals' Perception of Psychological Safety in Patients with Coronavirus (COVID-19)

BACKGROUND

Medical personnel act as the protectors of people's health by preventing, controlling, and treating emerging diseases, including the coronavirus infection. COVID-19 is a highly infectious and contagious disease which has presented the Iranian healthcare system with a variety of clinical challenges. There is a lack of research on clinical challenges in health crises especially those caused by emerging diseases, hence a need for more exploration of these clinical challenges and dilemmas. The present study aims to determine the different aspects of health professionals' perception of the psychological safety of patients infected with the coronavirus (COVID-19).

METHODS

The present study is a qualitative work which uses conventional content analysis. The participants were 17 health professionals who were responsible for COVID-19 patients and met the inclusion criteria. They were selected via purposeful sampling. The study lasted from February to March 2020. Data were collected through semi-structured, individual interviews which were conducted via video call. The collection of data was kept up to the point of saturation. The collected data were analyzed using the conventional content analysis method.

RESULTS

Three themes such as "respect for dignity", "comprehensive support" and "peaceful environment" with 11 categories were extracted from the findings of the study.

CONCLUSION

According to the results of the present study, patients infected with the coronavirus should be given care in a peaceful environment where they receive comprehensive support and have their dignity respected. Such conditions can guarantee the psychological safety of these patients and produce positive behavioral results on their part. Thus, it is essential that the cultural, professional, and organizational prerequisites of protecting all the dimensions of the psychological safety of these patients be provided.

An integrated HFMEA-DES model for performance improvement of general hospitals

Purpose

Healthcare failure mode and effect analysis (HFMEA) identifies potential risks and defines preventive actions to reduce the effects of risks. In addition, a discrete event simulation (DES) could evaluate the effects of every improvement scenario. Consequently, a proposed integrated HFMEA-DES model is presented for quality improvement in a general hospital.

Design/methodology/approach

In the proposed model, HFMEA is implemented first. As any risk in the hospital is important and that there are many departments and different related risks, all defined risk factors are evaluated using the risk priority number (RPN) for which related corrective actions are defined based on experts' knowledge. Then, a DES model is designed to determine the effects of selected actions before implementation.

Findings

Results show that the proposed model not only supports different steps of HFMEA but also is highly in accordance with the determination of real priorities of the risk factors. It predicts the effects of corrective actions before implementation and helps hospital managers to improve performances.

Practical implications

This research is based on a case study in a well-known general hospital in Iran.

Originality/value

This study takes the advantages of an integrated HFMEA-DES model in supporting the limitation of HFMEA in a general hospital with a large number of beds and patients. The case study proves the effectiveness of the proposed approach for improving the performances of the hospital resources.

Moral distress experienced by non-Western nurses: An integrative review

BACKGROUND

Moral distress has been identified as a significant issue in nursing practice for many decades. However, most studies have involved American nurses or Western medicine settings. Cultural differences between Western and non-Western countries might influence the experience of moral distress. Therefore, the literature regarding moral distress experiences among non-Western nurses is in need of review.

AIM

The aim of this integrative review was to identify, describe, and synthesize previous primary studies on moral distress experienced by non-Western nurses.

REVIEW METHOD

Whittemore and Knafl's integrative review methodology was used to structure and conduct the review of the literature.

RESEARCH CONTEXT AND DATA SOURCES

Key relevant health databases included the Ovid MEDLINE, CINAHL, Web of Science, and Google Scholar databases. Two relevant journals, Nursing Ethics and Bioethics, were manually searched.

ETHICAL CONSIDERATION

We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources.

FINDINGS

A total of 17 primary studies published between 1999 and 2019 were appraised. There was an inconsistency with regard to moral distress levels and its relationship with demographic variables. The most commonly cited clinical causes of moral distress were providing futile care for end-of-life patients. Unit/team constraints (poor collaboration and communication, working with incompetent colleagues, witnessing practice errors, and professional hierarchy) and organizational constraints (limited resources, excessive administrative work, conflict within hospital policy, and perceived lack of support by administrators) were identified as moral distress's stimulators. Negative impacts on nurses' physical, psychological, and spiritual well-being were also reported.

CONCLUSION

Further research is needed to investigate moral distress among other healthcare professions which may further build understanding. More importantly, interventions to address moral distress need to be developed and tested.

Nursing impact on chronic disease Medicaid health home patients: A qualitative study

BACKGROUND

Managing individuals with chronic health conditions in the primary care setting continues to be a significant challenge in the US health care system. This issue is further compounded for low-income individuals with both mental health and physical health chronic conditions. The Affordable Care Act provides opportunities to launch chronic disease Medicaid health homes (MHH) to address the existing health care gaps. Within a multidisciplinary team, the nurse serves an integral role as the main care manager and coordinator aimed to improve patient experiences, health outcomes, and lowering health care costs.

AIMS

The aim of this qualitative study is to assess the nurse's perception of their MHH role and how they may impact patient health care utilization patterns.

MATERIALS & METHODS

The qualitative study included a focus group of eleven nurses and individual interviews with seven nurses.

RESULTS

Six themes were identified that focus on how nurses can use a wide range of effective communication strategies and interpersonal skills to establish and maintain a nurse-patient relationship.

DISCUSSION

The six themes provided insight as to nurses' perceived role in an MHH and how they impact patient health outcomes. The overarching message addressed connecting with the patient and taking the time to find out what was important to them.

CONCLUSION

Nurses were able to impact patient health care utilization patterns.

Validation of the Brazilian Moral Distress Scale in Nurses

Background and Purpose

To determine the psychometric properties of the Brazilian Moral Distress Scale in Nurses (MDSN-BR).

Design

In this methodological, cross-sectional study, the criterion, content, and construct validation stages were presented.

Method

A 57-item questionnaire was applied to 1,227 brazilian nurses through an online form. The exploratory factor analyses revealed significant conceptual relations among its items in six constructs, expressing the consistency of the scale.

Results

The validated version of the instrument consists of six constructs and 49 items—Cronbach's alpha .980 (instrument) and of constructs: (a) (.942) Acknowledgment, power, and professional identity; (b) (.961) Safe and qualified care; (c) (.924) Defense of values and rights; (d) (.944) Work conditions; (e) (.933) Ethical infractions; (f) (.914) Work teams.

Conclusion

The results provide evidence supporting the reliability and trustworthiness of the scale in the selected population.

Ethical leadership, nursing error and error reporting from the nurses’ perspective

Background:

Nursing errors endanger patient safety, and error reporting helps identify errors and system vulnerabilities. Nursing managers play a key role in preventing nursing errors by using leadership skills. One of the leadership approaches is ethical leadership.

Aim:

This study determined the level of ethical leadership from the nurses’ perspective and its effect on nursing error and error reporting in teaching hospitals affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Research design:

This was a cross-sectional descriptive study.

Participants and research context:

A total of 171 nurses working in medical-surgical wards were selected through random sampling. Data collection was carried out using “ethical leadership in nursing, nursing errors and error reporting” questionnaires. Data were analyzed with SPSS20 using descriptive and analytical statistics.

Ethical considerations:

This study was approved by the Ethics Committee for Medical Research. Ethical considerations such as completing informed consent form, ensuring confidentiality of information, explaining research objectives, and voluntary participation were observed in the present study.

Findings:

The results showed that the level of nursing managers’ ethical leadership was moderate from the nurses’ point of view. The highest and the lowest levels were related to the power-sharing and task-oriented dimensions, respectively. There was a significant relationship between nursing managers’ level of ethical leadership with error rates and error reporting.

Conclusion:

The development of ethical leadership approach in nursing managers reduces error rate and increases error reporting. Programs designed to promote such approach in nursing managers at all levels can help reduce the level of error rate and maintain patient safety.

Strengthening ethical decision-making: the experience of Iranian nurses

AIMS

Ethical decision-making is a complex process that nurses perform daily. The aim of this study is to explain how ethical leaders in Iran strengthen ethical decision-making in their nursing teams.

METHOD

Data were collected using deep and semi-structured interviews with 20 Iranian nurses in 2015. Analysis was based on constant comparative analysis.

RESULTS

Ethical leaders strengthen ethical decision-making by promoting ethical commitment, developing an ethical atmosphere and guiding ethical decision-making.

CONCLUSION

The development of ethical decision-making in nursing can improve ethics-based nursing care.

Coping with moral distress - The experiences of intensive care nurses: An interpretive descriptive study

BACKGROUND

Over the last three decades, there has been a growing body of literature that has described moral distress as a prominent issue that negatively affects intensive care nurses. Yet, little focus has been given to how intensive care nurses cope and continue in their practice despite being exposed to moral distress.

OBJECTIVE

To describe intensive care nurses' experiences of coping with moral distress.

RESEARCH METHODS/SETTING

A qualitative design using an interpretative descriptive approach. Semi-structured interviews were conducted with seven intensive care nurses.

FINDINGS

The shared experience of coping with moral distress was explicated through the overarching theme of being Like Grass in the Wind. Four major themes emerged: Going Against What I Think is Best, Moral Distress - It's Just Inherent in Our Job, It Just Felt Awful, and Dealing with It. The findings also reflected actions associated with turning towards or turning away from morally distressing situations.

CONCLUSION

By developing coping strategies such as seeking social support, nurses can move forward in their practice and meaningfully engage with patients and families experiencing critical illness. When successful coping is not attained, nurses are at risk of becoming morally disengaged within their practice.

The effectiveness of narrative writing on the moral distress of intensive care nurses

BACKGROUND

Nursing is a profession that has always been accompanied with common ethical concerns. There are some evidences which indicate that narrative writing on traumatic experiences may improve an individual's emotional health.

OBJECTIVE

This study aimed to determine the effectiveness of narrative writing on moral distress of nurses working in intensive care unit.

RESEARCH DESIGN

This study was a clinical trial with pre- and post-test design. The frequency and intensity of moral distress was measured by a valid and reliable questionnaire (Corely) at baseline and after 8 weeks. The intervention group was asked to write about their deepest emotions and stressful experiences in the intensive care unit for 8 weeks.

PARTICIPANTS AND RESEARCH CONTEXT

Using consensus sampling, 120 nurses of intensive care unit and neonatal intensive care unit of the teaching hospitals (in Iran) were invited to and were randomly allocated into the intervention and control groups.

ETHICAL CONSIDERATIONS

Participation was voluntary, data were anonymized, and the confidentiality of the participating nurses and their institutions maintained. The ethical approval was obtained from an IRB or research ethics committee.

FINDINGS

In total, 106 nurses completed the trial consisting of 87.75% females. The mean work experience of nurses in the intervention and control groups was 7.21 ± 4.96 and 8.28 ± 5.45 years, respectively. Independent t-test showed no statistical difference neither in the intensity of moral distress (P = 0.8), nor in its frequency (P = 0.5) between the two groups.

DISCUSSION

As nurses constantly face ethical tensions, moral distress is a phenomenon that results from the different situations of critical care units. Their concern about receiving negative feedback from the managerial level may have influenced the outcome of the intervention.

CONCLUSION

Narratives writing by the nurses showed no effect on reducing the intensity and frequency of moral distress. It seems that due to the intensity of moral distress in clinical settings, we need to test variety solutions to reduce the problem.

Ethical conflict among nurses working in the intensive care units

BACKGROUND

Ethical conflict is a barrier to decision-making process and is a problem derived from ethical responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this phenomenon. A deep study of the phenomenon can help prevent and treat it.

OBJECTIVES

This study was aimed at determining the frequency, degree, level of exposure, and type of ethical conflict among nurses working in the intensive care units.

RESEARCH DESIGN

This was a descriptive cross-sectional research.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 382 nurses working in the intensive care units in Iranian hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in Nursing Questionnaire-Critical Care Version (Persian version).

ETHICAL CONSIDERATIONS

This study was approved by the Medical Research Ethics Committee. Ethical considerations such as completing the informed consent form, ensuring confidentiality of information, and voluntary participation were observed.

FINDINGS

The results showed that the average level of exposure to ethical conflict was 164.39 ± 79.06. The most frequent conflict was related to "using resources despite believing in its futility," with the frequency of at least once a week or a month (68.6%, n = 262). The most conflictive situation was violation of privacy (76.9%, n = 294). However, the level of exposure to ethical conflict according to the theoretical model followed was the situation of "working with incompetent staff." The most frequently observed type of conflict was moral dilemma.

CONCLUSION

The moderate level of exposure to ethical conflict was consistent with the results of previous studies. However, the frequency, degree, and type of ethical conflict were different compared to the results of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent ethical conflicts, and improve the nursing work environment.

The relationship between ethical conflict and nurses' personal and organisational characteristics

INTRODUCTION

Critical care nurses work in a complex and stressful environment with diverse norms, values, interactions, and relationships. Therefore, they inevitably experience some levels of ethical conflict.

AIM

The aim of this study is to analyze the relationship of ethical conflict with personal and organizational characteristics among critical care nurses.

METHODS

This descriptive-correlational study was conducted in 2017 on a random sample of 216 critical care nurses. Participants were recruited through stratified random sampling. Data collection tools were a demographic and professional characteristics questionnaire, the Ethical Conflict in Nursing Questionnaire-Critical Care Version, and the Organizational and Managerial Factors Questionnaire. The data were analyzed using the SPSS software (v. 22.0).

ETHICAL CONSIDERATIONS

All participants were informed about the study's aim and were assured that participation in and withdrawal from the study would be voluntary.

FINDINGS

The mean score of exposure to ethical conflict was 201.91 ± 80.38. The highest-scored conflict-inducing clinical situation was "working with professionally incompetent nurses or nurse assistants." Married nurses, nurses with official employment, nurses with master's degree, and nurses with the history of attending ethics education programs had significantly higher exposure to ethical conflict than the other nurses (p < 0.05). The significant predictors of exposure to ethical conflict were marital status, educational status, reward system, organizational culture, manager's conduct, and organizational structure and regulations (p < 0.05). These predictors accounted for 37.2% of the total variance of exposure to ethical conflict.

CONCLUSION

Critical care nurses experience moderate levels of exposure to ethical conflict. A wide range of personal and organizational factors can contribute to such exposure, the most significant of which is the professional incompetence of nursing colleagues, nurse assistants, and physicians. Therefore, many improvements at personal and organizational levels are needed to reduce critical care nurses' exposure to ethical conflict.

Ethical dilemmas in nursing: An integrative review

AIMS

To identify themes and gaps in the literature to stimulate researchers to develop strategies to guide decision-making among clinical nurses faced with ethical dilemmas.

BACKGROUND

The concept of ethical dilemmas has been well explored in nursing because of the frequency of ethical dilemmas in practice and the toll these dilemmas can take on nurses. Although ethical dilemmas are prevalent in nursing practice, frequently leading to moral distress, there is little guidance in the literature to help nurses resolve them.

DESIGN

This study is an integrative review of published research from 2000 to 2017.

METHODS

The keywords ethics, ethical dilemmas and nurs* were searched in CINAHL, PubMed, OVID and SCOPUS. Exclusion criteria were sources not available in English, not in acute care, and without an available abstract. Seventy-two studies were screened; 35 were retained. Garrard's matrix was utilised to analyse and synthesise the studies.

RESULTS

Ethical dilemmas arose from end-of-life issues, conflict with physicians or families, patient privacy concerns and organisational constraints. Differences were found in study location, and yet international research confirms that ethical dilemmas are universally prevalent and must be addressed globally to protect patients and nurses.

CONCLUSIONS

This review offers an analysis of the available evidence regarding ethical dilemmas in acute care, identifying themes, limitations and gaps in the literature. The gaps in quantitative intervention work, US paucity of research, and lack of comparisons across practice settings/nursing roles must be addressed. Further exploration is warranted in the relationship between ethical dilemmas and moral distress, the significance patient physical appearance plays on nurse determination of futility, and strategies for pain management and honesty.

RELEVANCE TO NURSING PRACTICE

Understanding and addressing gaps in research is essential to develop strategies to help nurses resolve ethical dilemmas and to avoid moral distress and burnout.

Moral distress and burnout in Iranian nurses: The mediating effect of workplace bullying

BACKGROUND

Moral distress and workplace bullying are important issues in the nursing workplace that appear to affect nurse's burnout.

AIM

To investigate the relationship between moral distress and burnout in Iranian nurses, as mediated by their perceptions of workplace bullying.

ETHICAL CONSIDERATIONS

The research was approved by the committee of ethics in research of the Urmia University of Medical Sciences.

METHOD

This is a correlation study using a cross-sectional design with anonymous questionnaires as study instruments (i.e. Moral Distress Scale-Revised, Maslach Burnout Inventory and The Negative Acts Questionnaire-Revised). Data were collected from 278 nurses from five teaching hospitals in Urmia, the capital of Western Azerbaijan, northwest of Iran. Structural equation modeling and bootstrapping procedures were employed to recognize the mediating role of their perceptions of workplace bullying.

RESULTS

The mean score of moral distress, burnout, and the Negative Acts Questionnaire-Revised Scale among the participants were 91.02 ± 35.26, 79.9 ± 18.27, and 45.4 ± 15.39, respectively. The results confirmed our hypothesized model. All the latent variables of study were significantly correlated in the predicted directions. The moral distress and bullying were significant predictors of burnout. Perception of bullying partially mediated the relationship between moral distress and burnout. The mediating role of the bullying suggests that moral distress increases burnout, directly and indirectly.

CONCLUSION

Nursing administrators should be conscious of the role of moral distress and bullying in the nursing workplace in increasing burnout.

Relationship between the use of intuition in clinical practice and the clinical competence of critical care nurses

INTRODUCTION

Clinical competency has been the main focus of nurse educational systems. To further it, the concept of intuition was introduced into nursing in the 1970s. Benner's theory proposed that greater use of intuition was linked to higher clinical competence; however, there is still a paucity of data to verify this theory. Therefore, the current study was conducted to assess the relationship between the use of intuition in clinical practice and the clinical competence of critical care nurses.

METHODS

In this correlational study, 88 critical care nurses were recruited as convenience. The tools included a 'use of intuition in clinical practice' scale devised by the researcher, and a 'clinical competence' instrument. The gathered data were analyzed by SPSS version 20.0 software, using descriptive and inferential statistics.

RESULTS

Of the 88 participants, 73.9% were women and 93.2% were at undergraduate level. The mean and standard deviation of participants' age and work experience was 32.29 ± 6.75 and 7.40 ± 5.68 years, respectively. The Pearson correlation test revealed no significant connection between the use of intuition in clinical practice and the clinical competence of critical care nurses (r = 0.091, P = 0.398), and produced similar results from the various demographic groups (P > 0.05).

CONCLUSION

In this study, no significant correlation between the use of intuition and clinical competence in critical care nurses was found. This could be attributed to intuition as a nursing skill being almost excluded from the educational curriculum of nursing schools, and some background factors.

Perceived organizational support and moral distress among nurses

BACKGROUND

Moral distress is prevalent in the health care environment at different levels. Nurses in all roles and positions are exposed to ethically challenging conditions. Development of supportive climates in organizations may drive nurses towards coping moral distress and other related factors. This study aimed at determining the level of perceived organizational support and moral distress among nurses and investigating the relationship between the two variables.

METHODS

This was a correlational-descriptive study. A total of 120 nurses were selected using random quota sampling method. A demographic questionnaire, Survey of Perceived Organizational Support, and Moral Distress Scale were used to collect the data which were analyzed using descriptive and analytical tests in SPSS20.

RESULTS

The mean perceived organizational support was low (2.63 ± 0.79). The mean moral distress was 2.19 ± 0.58, which shows a high level of moral distress. Moreover, Statistical analysis showed no significant relationship between perceived organizational support and moral distress (r = 0.01, p = 0.86).

CONCLUSION

Given the low level of perceived organizational support and high moral distress among nurses in this study, it is necessary to provide a supportive environment in hospitals and to consider strategies for diminishing moral distress.

A Second-Order Confirmatory Factor Analysis of the Moral Distress Scale-Revised for Nurses

Background:

Moral distress is a growing problem for healthcare professionals that may lead to dissatisfaction, resignation, or occupational burnout if left unattended, and nurses experience different levels of this phenomenon.

Objectives:

This study aims to investigate the factor structure of the Persian version of the Moral Distress Scale–Revised in intensive care and general nurses.

Research design:

This methodological research was conducted with 771 nurses from eight hospitals in the Mazandaran Province of Iran in 2017. Participants completed the Moral Distress Scale–Revised, data collected, and factor structure assessed using the construct, convergent, and divergent validity methods. The reliability of the scale was assessed using internal consistency (Cronbach’s alpha, Theta, and McDonald’s omega coefficients) and construct reliability.

Ethical considerations:

This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences.

Findings:

The exploratory factor analysis ( N = 380) showed that the Moral Distress Scale–Revised has five factors: lack of professional competence at work, ignoring ethical issues and patient conditions, futile care, carrying out the physician’s orders without question and unsafe care, and providing care under personal and organizational pressures, which explained 56.62% of the overall variance. The confirmatory factor analysis ( N = 391) supported the five-factor solution and the second-order latent factor model. The first-order model did not show a favorable convergent and divergent validity. Ultimately, the Moral Distress Scale–Revised was found to have a favorable internal consistency and construct reliability.

Discussion and conclusion:

The Moral Distress Scale–Revised was found to be a multidimensional construct. The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. Since the convergent and divergent validity of the scale were not confirmed in this study, further assessment is necessary in future studies.

Antecedents and Consequences of Therapeutic Communication in Iranian Nursing Students: A Qualitative Research

In recent years, particular attention has been paid to nursing students' therapeutic communication (TC) with patients, due to a strong emphasis on patient-centered education in the Iranian healthcare reform. However, various studies have highlighted the poor communication of future nurses. Therefore, researchers have used qualitative methodology to shed light on the antecedents and consequences of nursing students' TC and promote it. We carried out a conventional content analysis using semistructured interviews with a purposefully selected sample of 18 participants, including nursing instructors, students, and patients in hospitals affiliated to Tehran University of Medical Sciences. “Communication readiness,” “predisposing factors,” and “continuity of care” were identified as the three major themes. “Communication readiness” consisted of “physical readiness,” “academic readiness,” and “developmental readiness.” “Predisposing factors” included “contextual factors” and “educational condition.” “Continuity of care” included “patient satisfaction” and “improving nursing student's motivation to communicate with patients.” “Communication readiness” and “predisposing factors” constitute the antecedents of nursing student's TC with patients, and “continuity of care” is considered as its consequence. More attention needs to be paid by the regulators to TC instruction in both theoretical and clinical educational curriculum. Furthermore, all nurses must be informed about the importance of TC in promoting patient outcomes and quality of care.

Relationship between perceived organizational justice and moral distress in intensive care unit nurses

BACKGROUND:

The nature of the nursing profession pays more attention to ethics of healthcare than its therapeutic dimension. One of the prevalent moral issues in this profession is moral distress. Moral distress appears more in intensive care units due to the widespread need for moral decision-making regarding treatment and care in emergency situations. In this connection, organizational justice is of high importance and, as a significant motivational tool, leaves important impacts upon attitude and behavior of personnel.

AIM/OBJECTIVE:

This study aimed at investigation of the relationship between perceived organizational justice and moral distress in intensive care unit nurses.

RESEARCH DESIGN:

This is a descriptive-correlational research which examined the relationship between perceived organizational justice and moral distress in intensive care unit nurses.

PARTICIPANTS AND RESEARCH CONTEXT:

A total of 284 intensive care unit nurses were selected via census sampling. The data were collected through questionnaires and then were analyzed via SPSS-20 using Pearson and Spearman correlation tests.

ETHICAL CONSIDERATIONS:

This study was approved by the Committee of Ethics in Medical Research. Completion of informed consent form, guarantee of the confidentiality of information, explanation on purposes of the research, and voluntary participation in the study were moral considerations observed in this study.

FINDINGS:

There was a statistically significant negative correlation between the total perceived organizational justice and the total moral distress (p = 0.024, r = -0.137) and also between "procedural and interactional justice and errors" and "not respecting the ethics principles." Meanwhile, no relationship was found by the findings between distributive justice and dimensions of moral distress.

CONCLUSION:

According to the results of the study, there was a reverse significant relationship between moral distress and perceived organizational justice; therefore, the head nurses are expected to contribute to reduce moral distress and to increase perceived organizational justice in nurses.

Pediatric nurses’ ethical difficulties in the bedside care of children

Background:

Pediatric nurses experience ethically difficult situations in their everyday work. Several studies have been conducted to reveal ethical issues among pediatric nurses; we do not think their ethical difficulties have been explored sufficiently from their own perspective.

Objectives:

This study aimed to explore the ethical difficulties faced by pediatric nurses during bedside care for hospitalized children.

Methods:

A phenomenological approach was used to collect and analyze interview data from 14 female pediatric nurses in South Korea.

Ethical considerations:

Ethical review was obtained from an ethics committee. The participants were informed about the aim of the study, and voluntary participation, anonymous response, and confidentiality were explained to them.

Findings:

Three themes emerged from the analysis: ethical numbness in a task-oriented context, negative feelings toward family caregivers, and difficulty in expressing oneself in an authoritative climate. Conclusion and implications: We need to develop strategies to manage ethical difficulties at an institutional level. Furthermore, it is important that pediatric nurses have the opportunity to communicate with fellow nurses and other medical staff regarding ethical difficulties. In addition, cultivation of pediatric nurses’ moral, ethical, and philosophical thinking patterns requires the immediate provision of continuous education in nursing ethics at the site of clinical nursing, time to discuss ethical difficulties, and other supportive measures. Findings indicated that, to provide high-quality patient-centered care, we should enhance nurses’ ethical sensitivity and autonomy and improve the ethical climate in hospitals.

A Grounded theory study of the intention of nurses to leave the profession

Objective

this study explores the process of the development of an intention to leave bedside nursing.

Method

the process was studied from the perspective of 21 nurses using the grounded theory method. Data were collected using semi-structured interviews and the constant comparative method of Corbin and Strauss was used for data analysis.

Results

according to the participants, the two main categories, "social image of nursing", and "culture and structure of the bedside", were the contextual factors that influence why nurses are leaving bedside care provision. Disappointment with a perceived lack of progress or improvement in the clinical experience formed primary psychosocial concerns for the participants. Competence and a process of self-control were steps taken by the participants. These, associated with interventional conditions produced the outcomes of the loss of professional commitment and desire to leave bedside nursing. "Failure to integrate personal expectations with organizational expectations: in search of escape" was the central category of the study that linked the categories together.

Conclusion

the findings of this study provide useful information about the needs of nurses for overcoming the intention to leave bedside care. The identification of this process can help in recognizing emerging problems and providing solutions for them.