Moral distress in Turkish intensive care nurses

Adaptation and validation of moral distress thermometer in Chinese nurses

BACKGROUND

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

AIM

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

RESEARCH DESIGN

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

PARTICIPANTS AND RESEARCH CONTEXT

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

ETHICAL CONSIDERATIONS

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

RESULTS

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

CONCLUSION

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

Moral distress and moral sensitivity in clinical nurses

Health care providers are expected to have a certain moral sensitivity (MS) to make an ethical assessment. Moral distress (MD) is a common phenomenon in nursing. It can negatively affect nurses physically, psychologically, socially, and spiritually. This study aimed to investigate the relationship between MD and MS among nurses using a cross-sectional descriptive design. The study was conducted in two stages. The first stage was a methodological study that analyzed validity and reliability of the Measure of MD-Healthcare Professionals. The second stage was a descriptive- predictive analysis that investigated the relationship between MD and MS. The MD intensity and frequency scores of the participants were high and moderately high, respectively. There was no direct effect on the total score and frequency of MS and MD. However, a direct and significant negative effect of MS was seen on the intensity of MD. Based on the results of this study, MS should be considered as a measure in studies aimed at understanding MD among clinical nurses. Empowerment programs should be established to increase the awareness of health workers about ethical and moral situations and to support them to cope with the problems they experience in these areas.

The relationship between moral distress, individual and professional values in oncology nurses: A structural equation study

OBJECTIVES

This study examined the relationship between moral distress, individual and professional values in oncology nurses.

METHODS

Employing structural equation modeling, a descriptive-correlational study was conducted among 116 oncology nurses. Data were collected using the Moral Distress Scale-Revised Adult Nurses, the Nursing Professional Values Scale, and the Values Scale.

RESULTS

The mean moral distress frequency was evaluated as low (1.6 ± 0.7) and the intensity as moderate (1.9 ± 0.8). Both the Nursing Professional Values Scale and Values Scale subdimension mean scores were at levels evaluated as high. There was no specific value that stood out from the others. Structural equation modeling analysis showed that individual values were found to have a direct and negative significant effect on moral distress intensity (β = -0.70, p < 0.01) and frequency (β = -0.58, p <0.01) and professional values had a direct positive and significant effect on moral distress intensity (β = 0.37, p < 0.05) and frequency (β = 0.25, p < 0.05).

SIGNIFICANCE OF RESULTS

It is believed that more national and international studies need to be conducted to examine the relationship between the moral distress concept and values. While individual values were found to have a direct and negative significant effect on moral distress, professional values had a direct positive and significant effect on moral distress.

Moral distress among nurse leaders: A qualitative systematic review

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and APA PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions.

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

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

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.

Moral Distress and Its Relating Factors Among Pediatric Emergency Department Nurses: A Cross-Sectional Study

OBJECTIVES

Emergency services are patient circulation units that require chaos, trauma, and high tension. It was aimed to determine the moral distress levels of pediatric nurses in pediatric emergency and emergency departments and relevant factors.

METHODS

This study is a descriptive and cross-sectional study. It consists of 255 nurses with their data. The Participant Information Form and the Moral Distress Scale-Revised for Pediatric Nurses (MDS-R) were used to collect data.

RESULTS

In the study, the mean score of MDS-R frequency was found to be 27.36 ± 13.16, the mean score of MDS-R intensity to be 37.65 ± 17.53, and the mean total score of MDS-R to be 58.96 ± 39.40. It was determined that 93.7% of the nurses received training on moral distress, and education level was effective on moral distress levels of the nurses. The nurses working in the pediatric emergency service had higher moral distress levels than the nurses serving pediatric patients in the emergency department ( P(total MDS-R) = 0.02, P(frequency of MDS-R) = 0.008). Job satisfaction ( P(total MDS-R) = 0.003, P(frequency of MDS-R) < 0.001, P(intensity of MDS-R) < 0.001) and frequency of thinking about changing working unit ( P(frequency of MDS-R) = 0.02, P(intensity of MDS-R) = 0.01) were found to be effective on the level of moral distress. It was determined that the type of emergency service, the working time in the emergency service, and the level of job satisfaction significantly affected the total moral distress scores of the nurses ( P < 0.001, R2 = 0.09).

CONCLUSIONS

It was found in the study that nurses had low levels of moral distress; however, many factors relevant to working conditions were associated with moral distress. The pediatric emergency service nurses were determined to experience a higher moral distress compared with the emergency department nurses serving pediatric patients.

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

BACKGROUND

Moral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one's values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP).

METHODS

Eighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach's alpha was calculated for each domain and for the scale as a whole.

RESULTS

The scale as a whole showed a Cronbach's alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ²/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912).

CONCLUSIONS

We found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.

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

BACKGROUND

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

METHODS

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

RESEARCH DESIGN

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Individualized care perceptions and moral distress of intensive care nurses

BACKGROUND

Intensive care settings are characterized by their structure, which constantly changes in parallel with scientific and technological developments, the uncertainty of the lifeline between birth and death, the challenges in the fair distribution of limited resources, the participation of individuals in medical decisions, and witnessing the pain experienced by individuals. These characteristics also affect the level of moral distress, which can make it difficult for ICU nurses to provide the most appropriate individualized care for their patients.

AIMS

The purpose of this study was to determine the moral distress levels and individualized care perceptions of intensive care nurses.

STUDY DESIGN

This study employed a cross-sectional descriptive survey design.

METHODS

This descriptive study was conducted with 128 nurses working in the intensive care units of a university hospital in Turkey. Data were collected using an 'Information Form', 'the Moral Distress Scale', and 'the Individualized Care Scale-Nurse Version'.

RESULTS

78.9% of the nurses stated that there was staff shortage, and 36.0% stated that the physical conditions were not suitable for care in the intensive care units in which they worked. The mean score on the Moral Distress Scale was 79.2 ± 46.4. The mean total score on the Individualized Care Scale-Nurse Version was 3.5 ± 0.8.

CONCLUSION

This study revealed that the intensive care nurses had moderate levels of moral distress and good levels of individualized care perceptions although there was no significant relationship between their moral distress levels and individualized care perceptions. Also, the nurses adopted care behaviours supporting patients' feelings and autonomy.

RELEVANCE TO CLINICAL PRACTICE

In our study, the intensive care nurses did not reflect their moderate-level moral distress in the individualized care provided. It could be beneficial to measure intensive care nurses' moral distress and care levels at frequent intervals so that early precautions could be taken to prevent the accumulation of moral distress and care difficulties among intensive care nurses.

Moral distress to moral success: Strategies to decrease moral distress

BACKGROUND

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

AIM

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

DESIGN

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

PARTICIPANTS

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

ETHICAL CONSIDERATIONS

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

FINDINGS

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

DISCUSSION

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

CONCLUSIONS

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

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.

The severity of moral distress in nurses: a systematic review and meta-analysis

BACKGROUND

Moral distress is one of the most important problems that nurses face in their care of patients. Various studies have reported the frequency and severity of moral distress in nurses. However, to date, a comprehensive study that shows the results of these research across the world was not found, therefore due to the importance of this issue, its role in the health of nurses and patients, and the lack of general statistics about it worldwide, the present study was conducted to determine the frequency and severity of moral distress in nurses through a systematic review and meta-analysis.

METHODS

In this review study, searching national and international databases of SID, MagIran, IranMedex, IranDoc, Google Scholar, Embase, ScienceDirect, Scopus, CINHAL, PubMed, and Web of Science (WoS) between 2005 and February 2020 were extracted. The random-effects model was used for analysis, and the heterogeneity of studies with the I² index was investigated. Data were analyzed using Comprehensive Meta-Analysis (Version 2).

RESULTS

The frequency of moral distress in 9 articles with a sample size of 1576 persons was 1.7 ± 0.5 from (0-4), in 13 articles with a sample size of 1870 persons, 3.07 ± 0.1 from (0-5), in 6 articles with a sample size of 1316 persons, 3.2 ± 0.29 from (0-6), in 18 articles with a sample size of 1959 persons, 4.6 ± 0.518 from (1-7) and in 35 articles with a sample size of 3718 persons, 81.1 ± 4.6 from (216-30), and the severity of moral distress in 4 articles with a sample size of 1116 persons, 1.7 ± 0.37 from (0-4), in 5 articles with a sample size of 1282 persons, 2.6 ± 0.28 from (0-5), in 5 articles with a sample size of 944 persons, 3.9 ± 0.63 from (0-6) and in 8 articles with a sample size of 901 persons was 82.3 ± 5.4 (0-216).

CONCLUSION

The results of this study showed that the frequency and severity of moral distress in nurses are high and are a serious problem in nurses. Therefore, policymakers in this field should consider its role in the health of nurses and patients.

Stress of conscience and burnout among nurses in Turkey

PURPOSE

To investigate the validity and reliability of the Turkish version of the Stress of Conscience Questionnaire (SCQ) and to determine its relationship to burnout among Turkish nurses.

DESIGN AND METHODS

The sample of this study with a cross-sectional design comprised 375 nurses. The data were collected using the Maslach Burnout Inventory (MBI) and SCQ.

FINDINGS

The mean score of the nurses obtained from the overall SCQ was 85.36 ± 39.3 (min: 0; max: 225). The highest scored item by the nurses was related to "lack of energy to devote themselves to their families." There was a significant positive correlation between the Emotional Exhaustion-MBI scores and SCQ scores (r = 0.414, p < 0.001).

PRACTICE IMPLICATIONS

The Turkish version of SCQ is a valid and reliable tool among Turkish nurses and is associated with emotional exhaustion.

Validation of the Turkish version of the second victim experience and Support Tool (T-SVEST)

Objectives

Second victim experience defines the healthcare professionals involved in unexpected adverse patient events. The Second Victim Experience and Support Tool (SVEST) is a tool used to measure the second victim experience and the desired support resources. This study aims to carry out a cross-cultural adaptation of the SVEST and to evaluate the psychometric properties of the Turkish version (T-SVEST).

Methods

The T-SVEST was translated and adapted according to World Health Organization guidelines. 221 healthcare professionals including physicians, residents and nurses working at the emergency department, completed the survey. ​Cronbach's ​α ​values were assessed for reliability, and construct validity was assessed through confirmatory factor analysis in order to evaluate model fit.

Results

The global Cronbach's α score of the T-SVEST was 0.90. The final version of the TSVEST including 24 items was consistent with values between 0.83 and 0.89. The most consistent dimension was turnover intentions with a Cronbach's value of 0.89, it was followed by institutional support (Cronbach α = 0.88). After applying modifications suggested by ​confirmatory factor analysis, a final model including 9 factor-structure (7 dimensions and 2 outcome variables) and 24 items was significantly improved with acceptable ​comparative fit index, ​Tucker-Lewis index ​and ​root mean square error of approximation.

Conclusion

The Turkish version of the SVEST is a reliable and valid instrument that can be used to identify second victims and help implement support resources.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Moral distress in critical care nursing practice: A concept analysis

AIM

To provide a critical analysis of the concept of moral distress (MD) in critical care (CC) nursing.

BACKGROUND

Despite extensive inquiry pertaining to the legitimacy of MD within nursing discourse, some authors still question its relevancy to the profession. However, amid the global COVID-19 pandemic, MD is generating a significant amount of discussion anew, warranting the further exploration of the concept within CC nursing to provide clarity and expand on the definition.

DESIGN

Rodger's Evolutionary Concept Analysis method was used to guide this analysis.

METHODS

Related terms, attributes, antecedents, and consequences of MD were identified using current literature.

RESULTS

The results of this analysis demonstrate strong congruence between the attributes, antecedents, and negative consequences pertaining to MD. However, a new theme has emerged from this review of the contemporary literature, highlighting the potential unexpected positive outcomes perceived by nurses who experience MD, including the provision of better care, increased levels of empathy, and enhanced opportunities for ethical reflection.

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).

Alarm fatigue and moral distress in ICU nurses in COVID-19 pandemic

INTRODUCTION

Most ICU nurses feel overwhelmed by the variety of alarms at the same time. Therefore, nurses experience very stressful situations in relation to many responsibilities and care demands. This stressful condition has recently been exacerbated by COVID-19 and potentially endangers patient safety. The aim of this study was to investigate the alarm fatigue and moral distress of ICU nurses in COVID-19 crisis.

METHOD

This is a descriptive-analytical cross-sectional study (April-May 2021). Sampling was done by convenience among ICU nurses affiliated to Isfahan University of Medical Sciences, Iran. Data were collected using Nurses' alarm fatigue and the moral distress scale (MDS). Data were analyzed using ANOVA, independent t-test and multivariate logistic regression.

RESULT

The results showed that the mean score of alarm fatigue was moderate)19.08 ± 6.26 (and moral distress was low (33.80 ± 11.60). The results showed that there was a significant relationship between alarm fatigue and related training courses)P = .012(.So that, alarm fatigue in nurses who were trained in working with ventilators and alarm settings was significantly less than other nurses. Also, a significant relationship was found between moral distress and marital status(P = .001) and Shift type(P = .01). On the other hand, the risk of alarm fatigue was higher in participants who have a PhD. The results showed that no significant correlation was found between alarm fatigue and moral distress (r = 0.111, P = 0.195).

CONCLUSION

It is suggested that practical training courses on alarm management be included in the curriculum and the ICU nurses should have practical training before starting work in the ICU and on an annual basis. In order to protect nurses and ensure quality care of patients, nurse managers should reduce the number of rotating shifts of ICU nurses.

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.

Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study

Moral distress is a concern for all healthcare professionals working in all care settings. Based on our knowledge, no studies explore the differences in levels of moral distress in hospital and community settings. This study aims to examine the level of moral distress among healthcare professional working in community or hospital settings and compare it by demographic and workplace characteristics. This is a cross-sectional study. All the professionals working in the hospitals or community settings involved received personal e-mail invitations to participate in the study. The Moral Distress Thermometer was used to measure moral distress among healthcare professionals. Before data collection, ethical approval was obtained from each setting where the participants were enrolled. The sample of this study is made up of 397 healthcare professionals: 53.65% of the sample works in hospital setting while 46.35% of the sample works in community setting. Moral distress was present in all professional groups. Findings have shown that nurses experienced level of moral distress higher than other healthcare professionals (mean: 4.91). There was a significant differences between moral distress among different professional categories (H(6) = 14.407; p < 0.05). The ETA Coefficient test showed significant variation between healthcare professionals working in community and in hospital settings. Specifically, healthcare professionals who work in hospital experienced a higher level of moral distress than those who work in community settings (means 4.92 vs. means 3.80). The results of this study confirm that it is imperative to develop educational programs to reduce moral distress even in those settings where the level perceived is low, in order to mitigate the moral residue and the crescendo effect.

Moral distress in nursing students: Cultural adaptation and validation study

BACKGROUND

Moral distress, defined as moral suffering or a psychological imbalance, can affect nursing students. However, many new instruments or adaptations of other scales that are typically used to measure moral distress have not been used for nursing students.

AIM

This study aimed to translate, culturally adapt and evaluate the psychometric properties of an Italian version of the Moral Distress Scale for Nursing Students (It-ESMEE) for use with delayed nursing students (students who could not graduate on time or failed the exams necessary to progress to the next level).

RESEARCH DESIGN

The study used a cross-sectional research design.

PARTICIPANTS AND RESEARCH CONTEXT

Incidental sampling resulted in a sample of 282 delayed nursing students (mean age = 26.73 ± 4.43 years, 73% female) enrolled between May and August 2020 in a University of central Italy.

ETHICAL CONSIDERATIONS

The research protocol was approved by the internal review board of the university, and all participants provided their written informed consent.

RESULTS

The study confirmed a multidimensional second-order factorial structure for the It-ESMEE with five dimensions: improper institutional conditions to teach user care, authoritarian teaching practices, disrespect for the ethical dimension of vocational training, lack of competence of the teacher and commitment of ethical dimension of user care. The internal consistency was high (0.753-0.990 across the factors), and the standard error of measurement and smallest detectable change were adequate.

DISCUSSION

The It-ESMEE is able to assess moral distress in delayed nursing students with good validity and reliability. It can be used in research and to determine moral distress levels, helping teachers to monitor the condition in nursing students.

CONCLUSION

This instrument can help in comprehending moral distress, enabling students to develop coping and intervention strategies to maintain their well-being, and to ensure the quality of nurse education.

Moral Distress Among Interdisciplinary Critical Care Team Members at a Comprehensive Cancer Center

BACKGROUND

Moral distress (MD) has been linked to health care professional burnout, intent to leave, and decreased quality of care.

OBJECTIVES

The aim of this study was to describe the perceptions of MD among critical care interdisciplinary team members and assess the association of MD with team member characteristics.

METHODS

A descriptive cross-sectional design was used with interdisciplinary team members in an intensive care unit setting at an NCI-designated Comprehensive Cancer Center in the southeastern United States. The Measure of Moral Distress for Healthcare Professionals was provided to registered nurses, oncology technicians, providers, respiratory therapists, and ancillary team members (social workers, pharmacists, dietitians).

RESULTS

A total of 67 team members completed the survey. Mean responses for 3 items were higher than 8 (halfway point of scale): "Follow family's insistence to continue aggressive treatment even though I believe it is not in the best interest of patient" (mean [SD], 11.4 [4.8]); "Continue to provide aggressive treatment for a patient most likely to die regardless of this treatment when no one will make a decision to withdraw it" (mean [SD], 10.5 [5.3]); and "Witness providers giving 'false hope' to patient/family" (mean [SD], 9.0 [5.3]). Higher responses on the "Continuing to provide aggressive treatment" item was associated with having "considered leaving due to MD" (P = .027) and "considering leaving now due to MD" (P = .016). Higher total scores were related to having left or considered leaving a job (P = .04). When examining education level, registered nurses with a master's degree (n = 5) exhibited the most MD (P = .04).

CONCLUSION

This study suggests that the Measure of Moral Distress for Healthcare Professionals is useful in identifying areas for focused efforts at reducing MD for interdisciplinary teams.

Missed nursing care and its relationship with perceived ethical leadership

BACKGROUND

Determination of the factors affecting missed nursing care and the impact of ethical leadership is important in improving the quality of care.

AIM

This study aims to determine the missed nursing care and its relationship with perceived ethical leadership.

RESEARCH DESIGN

A cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

The sample consisted of 233 nurses, of whom 92.7% were staff nurses and 7.3% were charge nurses, who work in three different hospitals in Turkey. The study data were collected using a personal and professional characteristics data form, the Missed Nursing Care Survey, and the Ethical Leadership Scale.

ETHICAL CONSIDERATIONS

The study was approved by the non-interventional ethics committee of Dokuz Eylül University Ethics Committee for Noninvasive Clinical Studies. All participants' written and verbal consents were obtained.

FINDINGS

The most missed nursing care practices were ambulation, attending interdisciplinary care conferences, and discharge planning. According to the logistic regression analysis, sex, the number of patients that the nurse is in charge of giving care, the number of patients discharged in the last shift, and satisfaction with the team were determined as factors affecting missed care. No significant relationship was found between ethical leadership and missed nursing care (p > 0.05), and a weak but significant relationship was found between the clarification of duties/roles subscale and missed nursing care (r = -0.136, p < 0.05).

DISCUSSION

Ethical leaders should collaborate with policy-makers at an institutional level to particularly achieve teamwork that is effective in the provision of care, to control missed basic nursing care, and to organize working hours and at the country level to determine roles and to increase the workforce.

CONCLUSION

The results of this study contribute to the international literature on the most common type of missed nursing care, its reasons, and the relationship between the missed care and ethical leadership in a different cultural context.

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.

Caring behaviors, moral sensitivity, and emotional intelligence in intensive care nurses: A descriptive study

PURPOSE

To evaluate the relationship of caring behaviors with moral sensitivity, emotional intelligence and descriptive characteristics in intensive care nurses.

METHOD

Descriptive study. The sample of this study consisted of 156 nurses. The data were collected using introductory information form, caring behaviors inventory, moral sensitivity questionnaire, and emotional intelligence scale. The factors affecting caring behavior were determined using stepwise multiple linear regression.

FINDING

It was determined that high education level, working in shifts, as well as appraisal of emotion subscale of emotional intelligence scale and also autonomy, expressing benevolence, and following praxis subscales of moral sensitivity questionnaire were high predictors for caring behaviors.

PRACTICE IMPLICATIONS

Descriptive characteristics, moral sensitivity, and emotional intelligence are related to high caring behavior in intensive care nurses.

The Association between Moral Distress and Moral Courage in Nurses: A Cross-Sectional Study in Iran

Background:

Moral distress and moral courage among healthcare professionals have received considerable attention in recent years. However, there is a paucity of studies investigating these topics among nurses. Thus, the present study aimed to evaluate the association between moral distress and moral courage among nurses in an Iranian sample population.

Materials and Methods:

The present cross-sectional study was conducted during February–December 2018. Corley's Moral Distress (MDS-R) and Sekerka's moral courage scales were used to collect the data. MDS-R is a 21-items scale which includes frequency and intensity ranges from 0 (never) to 4 (very frequently) and 0 (none) to 4 (great extent), respectively. In addition, the moral courage scale contains 15 items ranging from “never true” (1 point) to “always true” (7 points). In total, 225 eligible nurses were entered into this study. Finally, SPSS-16 was used for statistical analysis at the α = 0.05 level.

Results:

The mean scores of the frequency and intensity of moral distress and moral courage were 45.41 (95% CI = 43.37-47.45), 44.24 (95% CI = 42.98-45.42), and 59.63 (95% CI = 58.50-60.87), respectively. Eventually, a significant relationship was found between the moral courage and frequency of moral distress (r = 0.46, p < 0.001) and the intensity of moral distress (r = 0.73, p < 0.001).

Conclusions:

In general, encouraging healthcare managers and administrators is considered as crucial for developing supportive structures and highly sensitive management which promotes moral courage while reducing moral distress in nurses' work setting.

Instruments for Detecting Moral Distress in Clinical Nurses: A Systematic Review

Moral distress (MD) has become a seriously negative problem experienced by healthcare professionals, especially clinical nurses. Early and accurate detection of MD by the validated and reliable instrument is critically important to further develop an effective intervention strategy. We performed the current systematic review to comprehensively summarize the evidence of instruments for the detection of MD in clinical nurses. The research design was a systematic literature review. We assigned 2 investigators to independently search potential studies in PubMed, EMBASE, and China National Knowledge Infrastructure (CNKI) from their inception to June 2020. We used data extraction table extracting essential information, and the modified critical appraisal tool evaluating the reliability and validity of eligible instruments. Finally, we qualitatively summarized results of all included instruments. No ethical approval was required because this systematic review was performed based on published studies. We included 16 eligible studies covering 10 original and 6 revised or modified instruments for the final analysis. The overall quality of all instruments was moderate because test-retest reliability was inadequately examined in most instruments. Of 16 instruments, MDS-revised (MDS-R) was broadly validated and employed in different working or cultural settings. Meanwhile, it also extensively expands to specifically detect MD. Moreover, other instruments including moral distress risk scale (MDSR) and moral distress thermometer (MDT) should be further validated and utilized because it covered the gap missed by most instruments. Although several instruments have been made available for clinical nurses, some of them have inadequate psychometric properties test, especially test-retest reliability evaluation. Meanwhile, most of them have not be validated and employed in other working or cultural settings. We therefore suggested further studies to validate the psychometric properties of existing instruments and then employed instruments with high reliability and validity to detect MD in clinical nurses.

CULTURAL ADAPTATION AND VALIDATION OF THE MORAL SENSITIVITY QUESTIONNAIRE AMONG BRAZILIAN NURSES

ABSTRACT Objective: cultural adaptation and validation of the Moral Sensitivity Questionnaire to assess moral sensitivity among Brazilian nurses. Method: methodological study with 106 nurses from two hospitals located in the south of Brazil. The instrument was culturally adapted according to international guidelines, following six steps: translation, reconciliation of translated versions, back translation, expert panel, pretest, and final review. The Brazilian version was validated in the Brazilian context using factor analysis and Cronbach’s alpha. Results: after the expert panel’s assessment, pretest, and verification of face and content validity, the instrument was considered satisfactory to be applied among Brazilian nurses. Six constructs were identified: Respect for patients’ autonomy, modified autonomy, experiencing moral conflict, having confidence in medical and nursing knowledge, structuring moral meanings, and teamwork. The instrument presented satisfactory internal consistency, with a Cronbach’s alpha equal to 0.62; the Cronbach’s alpha of the six constructs ranged from 0.60 to 0.67. Conclusion: the Brazilian version of the Moral Sensitivity Questionnaire is valid and reliable to be applied among Brazilian nurses and can improve understanding of factors involving decision-making when facing ethical conflicts.

Instruments to assess moral distress among healthcare workers: A systematic review of measurement properties

BACKGROUND

An increasing number of professionals are challenged by the evolution of modern healthcare and society, often characterized by more expectations with reduced resources. Moral distress is among the psychophysical conditions now most under investigation in order to improve the wellbeing of professionals, the sustainability of organizations and the quality of care. Over the last decades, several instruments have been developed to assess the frequency or intensity of moral distress in different studies. Yet, there has not been, so far, a systematic assessment of the qualitative properties of the various instruments measuring moral distress in healthcare workers based on a universally accepted standardized framework.

OBJECTIVE

(1) To identify all instruments for the measurement of moral distress available in recent literature; (2) to evaluate the evidence regarding their measurement properties; (3) to facilitate the selection of the most appropriate instrument to be adopted in practice and research.

DESIGN

Systematic literature review.

DATA SOURCES

PubMed, CINAHL, and PyscINFO.

REVIEW METHODS

The COnsensus-based Standards for the selection of health Measurement INstruments checklist was used to evaluate the methodological quality of the identified studies. The quality of measurement properties of each instrument was evaluated using Terwee's quality criteria.

RESULTS

Among the 1268 studies found, 88 full-text articles evaluated moral distress adopting different tools. Thirty two of them had a methodological design. The measurement instruments assessed in this review are different in terms of targeted population and items. The instruments were then divided into two main categories: (1) Corley's instruments on moral distress (Moral distress scale and Moral Distress Scale - Revised) and (2) instruments not directly derived from Corley's moral distress theory (Moral Distress thermometer, Moral Distress Risk Scale, Ethical Stress Scale or Moral Distress in Dementia Care Survey). The first set is the most frequently studied and used in different clinical settings and healthcare populations. A variety of psychometric properties have been evaluated for each instrument, revealing different qualities in the methodology used.

CONCLUSIONS

Several instruments assessing moral distress in healthcare workers have been identified and evaluated in this systematic review. Based on the criteria used here, Corley's instruments on moral distress seems to be the most useful and most appropriate to the clinical setting for practice and research purposes.

TWEETABLE ABSTRACT

The aim of this systematic review was to identify the instruments measuring moral distress now available in the literature, in order to (1) assess the evidence about their measurement properties, (2) support the selection of the most appropriate instrument to be used in practice and research.

Validity and reliability study of the Moral Distress Questionnaire in Turkish for nurses

Objective:

to determine the validity and reliability of the Turkish language version of the Moral Distress Questionnaire for nurses.

Method:

methodological study whose sample consisted of 200 nurses working in the internal medicine and surgery clinics of a university hospital. Data was collected using the personal information form and the Moral Distress Questionnaire for nurses.

Results:

in the Main Components Analysis, the items were grouped under three factors. Findings regarding confirmatory factor analysis: chi-square goodness: 2.28, goodness of fit index: 0.88, comparative fit index: 0.88, non-normed fit index: 0.86, root mean square error of approximation: 0.07. The Cronbach’s alpha coefficient was found to be 0.79 as a result of the analysis conducted in order to test the internal consistency of the scale. It was seen that these three factors explained 44.92% of the total variance.

Conclusion:

in this present study, the Turkish version of the Moral Distress Questionnaire was found to be valid and reliable for the Turkish society. It is recommended that the Moral Distress Questionnaire for nurses should be used in future studies to be conducted with nurses in order to investigate of issues of ethical dilemma.

Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature

The concept of moral distress comes from nursing ethics, and was initially defined as ‘…when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation.

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.

Prevalence of severe moral distress among healthcare providers in Saudi Arabia

Background

Moral distress is a serious problem in healthcare environments that requires urgent attention and management. It occurs when healthcare providers are unable to provide the care that they feel is right or take, what they believe to be, ethically appropriate actions for their patients. Thus, this study aims to examine moral distress among nurses and physicians working in tertiary teaching hospitals in Saudi Arabia, as well as to evaluate the level of association between moral distress and turnover.

Methods

This cross-sectional study, which employed an anonymous 21-item Moral Distress Scale, was undertaken at a large medical institution located in different regions of Saudi Arabia. The data were analyzed using bivariate analyses, and logistic regression.

Results

Of the 342 participants, 239 (69.9%) were nurses/staff physicians and 103 (30.1%) were fellows/consultants. Approximately 24.3% of respondents experienced severe moral distress, whereas 75.7% reported mild moral distress. There was no statistically significant difference between men and women in terms of moral distress. Age was found to be a notable factor: moral distress was significantly higher in those younger than 37 years compared to those 37 years and older (P=0.015). Less than half of the participants (137, 42.8%) indicated their willingness to leave their jobs. A significant association was observed between severe moral distress and leaving the career (OR=3.16; P<0.01). Job category was also an important factor: nurses/staff physicians were almost two times more likely (OR =1.95, P=0.038) to leave their positions compared to fellows/consultants.

Conclusion

This study revealed that moral distress, which is a serious problem that compromises the well-being of caregivers, was a predictive variable for the intention of healthcare providers to leave their jobs. Therefore, it should be routinely examined, and efficient action plans should be implemented to alleviate its consequences.

Severity and frequency of moral distress among midwives working in birth centers

BACKGROUND

When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems.

RESEARCH OBJECTIVE

The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers.

RESEARCH DESIGN

This study is a descriptive cross-sectional research. Researcher-made questionnaire was used to gather data.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census.

ETHICAL CONSIDERATIONS

Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained.

FINDINGS

The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010).

DISCUSSION

The midwives' moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses.

CONCLUSION

After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures.

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.

The effect of nurses' ethical leadership and ethical climate perceptions on job satisfaction

BACKGROUND

The development of ethical leadership approaches plays an important role in achieving better patient care. Although studies that analyze the impact of ethical leadership on ethical climate and job satisfaction have gained importance in recent years, there is no study on ethical leadership and its relation to ethical climate and job satisfaction in our country.

OBJECTIVES

This descriptive and cross-sectional study aimed to determine the effect of nurses' ethical leadership and ethical climate perceptions on their job satisfaction.

METHODS

The study sample is composed of 285 nurses who agreed to participate in this research and who work at the internal, surgical, and intensive care units of a university hospital and a training and research hospital in İzmir, Turkey. Data were collected using Ethical Leadership Scale, Hospital Ethical Climate Scale, and Minnesota Satisfaction Scale. While the independent sample t-test, analysis of variance, Mann-Whitney U test, and Kruskal-Wallis test were used to analyze the data, the correlation analysis was used to determine the relationship between the scales.

ETHICAL CONSIDERATIONS

The study proposal was approved by the ethics committee of the Faculty of Medicine, Dokuz Eylül University.

FINDINGS

The nurses' mean scores were 59.05 ± 14.78 for the ethical leadership, 92.62 ± 17 for the ethical climate, and 62.15 ± 13.46 for the job satisfaction. The correlation between the nurses' ethical leadership and ethical climate mean scores was moderately positive and statistically significant (r = +0.625, p = 0.000), was weak but statistically significant between their ethical leadership and job satisfaction mean scores (r = +0.461, p = 0.000), and was moderately positive and statistically significant between their ethical climate and job satisfaction mean scores (r = +0.603, p = 0.000).

CONCLUSION

The nurses' ethical leadership, ethical climate, and job satisfaction levels are moderate, and there is a positive relationship between them. The nurses' perceptions of ethical leadership are influenced by their educational status, workplace, and length of service.

Relationship between moral distress and ethical climate with job satisfaction in nurses

BACKGROUND:

Moral distress and ethical climate are important issues in the workplace that appear to affect people's quality of work life.

OBJECTIVES:

This study was conducted to determine the relationship of moral distress and ethical climate to job satisfaction in critical care nurses.

MATERIALS AND METHODS:

This descriptive-correlation study was conducted on 142 critical care nurses, selected from five social security hospitals in north Iran through census sampling. Data were collected using a demographic questionnaire, the Moral Distress Scale-Revised, the Olson's Hospital Ethical Climate Survey, and the Brayfield and Rothe Job Satisfaction index.

ETHICAL CONSIDERATIONS:

The research project was approved by the Ethics Committee of Mazandaran University of Medical Sciences and the Medical Deputy of the Social Security Organization.

FINDINGS:

The mean scores obtained by the critical care nurses for moral distress, ethical climate, and job satisfaction were 87.02 ± 44.56, 3.51 ± 0.53, and 62.64 ± 9.39, respectively. Although no significant relationships were observed between moral distress and job satisfaction, the relationship between ethical climate and job satisfaction was statistically significant (p < 0.05).

CONCLUSION:

Identifying ethical stressors in the workplace and giving proper feedback to the authorities to eliminate these factors and improve the ethical climate in these workplaces can help enhance job satisfaction in nurses and lead to higher quality care.

Psychometric evaluation of the Moral Distress Risk Scale: A methodological study

BACKGROUND:

Moral distress is a kind of suffering that nurses may experience when they act in ways that are considered inconsistent with moral values, leading to a perceived compromise of moral integrity. Consequences are mostly negative and include physical and psychological symptoms, in addition to organizational implications.

OBJECTIVE:

To psychometrically test the Moral Distress Risk Scale.

RESEARCH DESIGN:

A methodological study was realized. Data were submitted to exploratory factorial analysis through the SPSS statistical program.

PARTICIPANTS AND RESEARCH CONTEXT:

In total, 268 nurses from hospitals and primary healthcare settings participated in this research during the period of March to June of 2016.

ETHICAL CONSIDERATIONS:

This research has ethics committee approval.

FINDINGS:

The Moral Distress Risk Scale is composed of 7 factors and 30 items; it shows evidence of acceptable reliability and validity with a Cronbach's α = 0.913, a total variance explained of 59%, a Kaiser-Meyer-Olkin = 0.896, and a significant Bartlett <0.001.

DISCUSSION:

Concerns about moral distress should be beyond acute care settings, and a tool to help clarify critical points in other healthcare contexts may add value to moral distress speech.

CONCLUSION:

Psychometric results reveal that the Moral Distress Risk Scale can be applied in different healthcare contexts.

Psychometric evaluation of the Moral Distress Scale–Revised among Iranian Nurses

Background:

Experiencing moral distress is traumatic for nurses. Ignoring moral distress can lead to job dissatisfaction, improper handling in the care of patients, or even leaving the job. Thus, it is crucial to use valid and reliable instruments to measure moral distress.

Objective:

The purpose of this study was to determine the reliability and the validity of the Persian version of the Moral Distress Scale–Revised among a sample of Iranian nurses.

Research design:

In this methodological study, 310 nurses were recruited from all hospitals affiliated with the Qazvin University of Medical Sciences from February 2014 to April 2015. Data were collected using a demographic questionnaire and the Moral Distress Scale–Revised. The construct validity of the Moral Distress Scale–Revised was evaluated using principal component analysis and confirmatory factor analysis. Internal consistency reliability was assessed with Cronbach’s alpha.

Ethical considerations:

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

Findings:

The construct validity of the scale showed four factors with eigenvalues greater than one. The model had a good fit ( χ2(162) = 307.561, χ2/ df = 1.899, goodness-of-fit index = .904, comparative fit index = .927, incremental fit index = .929, and root mean square error of approximation (90% confidence interval) = .049 (.040–.057)) with all factor loadings greater than .5 and statistically significant. Cronbach’s alpha coefficients were .853, .686, .685, and .711for the four factors. Moreover, the model structure was invariant across different income groups.

Discussion and conclusion:

The Persian version of the Moral Distress Scale–Revised demonstrated suitable validity and reliability among nurses. The factor analysis also revealed that the Moral Distress Scale–Revised has a multidimensional structure. Regarding the proper psychometric characteristics, the validated scale can be used to further research about moral distress in this population.