The relationship between moral distress and clinical care quality among nurses: an analytical cross-sectional study

BACKGROUND

Nurses constitute the largest group of service providers in the healthcare system and significantly influence the quality of healthcare services. Factors such as ethical considerations may be related to the quality of care. This study aimed to determine the relationship between moral distress and the quality of clinical care among nurses working in Gonabad, Iran.

METHODS

An analytical cross-sectional study was conducted on 252 nurses working in emergency, internal medicine, surgery, psychiatry, critical care and maternity wards at Allameh Bohlool Hospital from May to July 2023. This research used demographic information questionnaire, the revised Moral Distress Scale (MDS-R), and the Quality Patient Care Scale (QUALPAC). The significance level for the study was set at p < 0.05.

RESULTS

There was a significant relationship between the frequency of moral distress and the quality of clinical care (p = 0.032), as well as between the intensity of moral distress and the quality of clinical care (p = 0.043). Nurses who experienced moral distress more frequently and intensely provided better quality care. However, there was no significant relationship between the effect of moral distress and the quality of clinical care (r = 0.032, p = 0.619). Additionally, a significant statistical relationship was found between the intensity of moral distress and the physical dimension of clinical care quality (r = 0.171, p = 0.007), indicating that increased moral distress intensity was associated with higher quality of physical care.

CONCLUSIONS

Nurses who experience higher levels of moral distress, both in terms of frequency and intensity, perform better in the care they provide and deliver it in the best possible manner, particularly in the physical dimension of care.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

One university hospital and six general hospitals.

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

"Moral spaces": A feasibility study to build nurses' ethical confidence and competence

Background: Pre-licensure ethics nursing education does not adequately prepare and instill confidence in nurses to address ethical issues, and yet ethics education provides nurses with greater confidence to take moral action, which can mitigate the negative effects of moral distress. Objectives: To assess the feasibility and acceptability of a nursing ethics education program that included simulated case-based ethics competencies as a form of evaluation. The program aimed at building nurses' ethical knowledge and confidence to respond to ethical challenges in practice. Research design: A prospective, longitudinal, correlational, single-cohort feasibility study using an investigator-developed survey and intervention field data. Participants and research context: Registered nurses were recruited from an academic quaternary-care medical center and 9 small- to mid-sized regional hospitals within one health system in the Midwest United States. Ethical considerations: IRB approval was obtained. Participants could complete the educational program regardless of research process participation. Findings: Of 20 participants, 19 (95%) provided post-program surveys and 18 completed competencies. Median (IQR) scores with quartiles for scheduling, timing, and length of sessions were all 10.0 [9.0, 10.0], and participants perceived that the content was interesting, increased knowledge and confidence in ethics, increased skills in providing ethical care, and would recommend the program to colleagues. Of factors, an increase in ethics knowledge had the highest "always agree" (17, 89.5%) response. Most participants reported that ethics competencies were appropriate 9.0 [9.0, 10.0] and sufficiently challenging 10.0 [9.0, 10.0]. Discussion: The education program developed nurses' ethics knowledge and confidence. The single-cohort feasibility design provided early-stage intervention outcomes; however, a larger randomized controlled trial would substantiate program value. Conclusion: This novel ethics education program was highly feasible and acceptable to hospital-based nurses who reported increased knowledge and confidence in providing ethical care. Simulated case-based ethics competencies were an appropriate evaluation method.

Factors associated with moral sensitivity among nurses in adult intensive care units: A cross-sectional study in China

BACKGROUND

Moral sensitivity may play a role in dealing with ethical issues in ICUs. However, the moral sensitivity of adult ICU nurses in China and its predictors have not been well investigated.

AIMS

To analyse the moral sensitivity of intensive care unit (ICU) nurses and its predictors.

STUDY DESIGN

A cross-sectional study through convenience sampling was conducted in the ICUs of five hospitals in China between November and December 2022. A total of 331 ICU nurses were recruited. Data were obtained using a self-developed socio-demographic characteristic questionnaire, the Moral Sensitivity Questionnaire, the Jefferson Scale of Empathy-Health Professionals and the Organizational Climate Scale for Nursing. The participating institutions received a link to the tools used for online data collection, which they then forwarded to nursing staff.

RESULTS

The valid response rate was 96.98% (n = 321). The total mean moral sensitivity score of nurses was 43.04 ± 5.95. The mean scores for empathic ability and organizational climate for nursing were 91.97 ± 17.88 and 101.28 ± 14.77, respectively. Regression analyses revealed that the primary factors associated with moral sensitivity among critical care nurses included work tenure (p < .05), empathic ability (p < .001) and organizational climate (p < .001).

CONCLUSIONS

High levels of moral sensitivity were found in critical care nurses in China. Work tenure, empathic ability and organizational climate were significant predictors of moral sensitivity in critical care nurses.

RELEVANCE TO CLINICAL PRACTICE

To enhance the ethical sensitivity of ICU nurses, we suggest to strengthen the training of novice nurses so that they can better face the moral dilemma in clinical practice. In addition, organizational managers should also take measures to create a positive and harmonious working atmosphere, promote the application of moral knowledge in nursing practice and enhance their moral sensitivity.

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

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

The effect of simulated problem learning in nursing ethics on moral sensitivity, empathy and critical thinking of nursing students: A quasi-experimental study

AIM

Compare the effects of Simulation with problem-based learning (SPBL) and Problem-based learning (PBL) in nursing ethics education on nursing students' moral sensitivity, empathy, critical thinking, test scores and teaching satisfaction.

BACKGROUND

Promoting nursing students' individual and ethical and abilities through education is an essential way to improve their ethical performance and build trustful relationship with patients. Despite significant efforts in this area, few have evaluated the effectiveness of Simulation with problem-based learning and Problem-based learning as applied to nursing ethics education.

DESIGN

A quasi-experimental design based on a non-equivalent control group pre-test/post-test.

METHODS

A quasi-experimental design was used. Participants were 161 undergraduate nursing students from two levels of a university, 88 subjects in the experimental group were taught using Simulation with problem-based learning and 73 subjects in the control group were taught using Problem-based learning. A pre-test, post-test and questionnaire were used to assess the effectiveness of student nursing ethics education. χ2 test was used to examine group differences in students' characteristics and satisfaction with teaching post-intervention. Student's t-test was used to assess group differences in scale scores and test scores.

RESULTS

Compared to the pre-test, empathy as well as critical thinking were significantly higher in the PBL group (P<0.05), but there was no significant change in moral sensitivity (P>0.05); moral sensitivity, empathy and critical thinking were significantly higher in the SPBL group (P<0.05). Moreover, this study also showed that improvement in moral sensitivity, empathy, critical thinking and grades was more significant in the SPBL group of nursing students compared to the PBL group (P<0.05) and no statistically significant difference was found between the two groups in terms of teaching satisfaction (P>0.05).

CONCLUSION

The use of Simulation with problem-based learning in nursing ethics education has a positive impact on nursing students' competency development and knowledge acquisition. Nurse educators should consider this teaching method and promote change to increase the effectiveness of nursing ethics education.

Relationship between moral resilience and secondary traumatic stress among ICU nurses: A cross-sectional study

BACKGROUND

Since the outbreak of COVID-19, researchers worldwide have focused more on the issue of secondary traumatic stress (STS) experienced by nurses. This stress has an adverse effect on the health of nurses and the quality of nursing care, potentially undermining the stability of the nursing team and hindering the ability to meet the growing demand for nursing services. The impact of the COVID-19 pandemic, and the rise in global demand for ICU nursing, has placed a significant strain on ICU nurses, severely damaging their mental and physical health. Notably, ICU nurses also face high levels of moral distress, and moral resilience can effectively alleviate this distress and improve the quality of care.

AIMS

This study aimed to examine the levels of moral resilience and STS among ICU nurses, to explore their relationship and identify the factors influencing STS.

STUDY DESIGN

This cross-sectional study involved 229 ICU nurses from two tertiary hospitals in Xi'an, China, who participated between November and December 2023. The data were collected through email using anonymous electronic questionnaires, encompassing a self-designed demographic- and work-life-related characteristic questionnaire; the Rushton Moral Resilience Scale; and the Secondary Traumatic Stress Scale. Descriptive statistics, t-tests, analysis of variance and hierarchical regression analysis were performed to analyse the data.

RESULTS

The findings of the study indicated that ICU nurses' moral resilience and STS scores were at an intermediate level. Hierarchical regression analysis indicated that STS was negatively correlated with the subscales of the Rushton Moral Resilience Scale, specifically moral adversity coping (β, -0.156; 95% CI, -1.241 to -0.039) and relational integrity (β, -0.245; 95% CI, -1.453 to -0.388), which are significant predictors of STS. Additionally, good sleep quality (β, -.396; 95% CI, -14.948 to -7.117) and seeking psychological counselling because of work difficulties (β, .107; 95% CI, 0.237-9.624) emerged as significant predictors of STS among ICU nurses, with the model's explanation of the variance in STS increasing to 45.5%, △R2 = .167, F = 16.482 (p < .001).

CONCLUSION

This study found that ICU nurses have moderate levels of moral resilience and STS, which are negatively correlated. This suggests that improving the moral resilience of ICU nurses may help reduce their STS levels.

RELEVANCE TO CLINICAL PRACTICE

The study revealed that ICU nurses' moral resilience and secondary traumatic stress levels were at a moderate level, indicative of the need to take measures to enhance their moral resilience and reduce their secondary traumatic stress, as their presence not only affects the health of ICU nurses but also diminishes the quality of care and increases turnover rates.

Development of burnout and moral distress in intensive care nurses: An integrative literature review

AIMS

To describe, through an integrative literature review, the factors contributing to the development of burnout and moral distress in nursing professionals working in intensive care units and to identify the assessment tools used most frequently to assess burnout and moral distress.

METHODS

An integrative literature review was carried out. PubMed, CINAHL, PsycINFO, SciELO, Dialnet, Web of Science, Scopus, and Cochrane databases were reviewed from January 2012 to February 2023. Additionally, snowball sampling was used. The results were analysed by using integrative synthesis, as proposed by Whittemore et al., the Critical Appraisal Skills Programme for literature reviews, the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for quantitative observational studies, and the Joanna Briggs Institute checklist for qualitative research were used to evaluate evidence quality.

RESULTS

Forty-one articles were selected for review: 36 were cross-sectional descriptive articles, and five were literature reviews. The articles were grouped into five-factor categories: 1) personal factors, 2) organisational factors, 3) labour relations factors, 4) end-of-life care factors, and 5) factors related to coronavirus disease 2019 (COVID-19). The Maslach Burnout Inventory-Human Services Survey and the Moral Distress Survey-Revised instruments were the most commonly used to measure burnout and moral distress.

CONCLUSIONS

This review highlights the multiple personal, organisational, relational, situational, and end-of-life factors promoting burnout and moral distress among critical care nurses. Interventions in these areas are necessary to achieve nurses' job satisfaction and retention while improving nurses' quality of care.

Factors contributing to moral distress among intensive care nurses: A scoping review

Background: The intensive care unit (ICU) is a busy and complex workplace, and several work-related and personal factors are known to make ICU nurses more vulnerable to moral distress than other healthcare professionals. It is crucial to identify these factors to guide future studies and preventive strategies. This scoping review explores such factors to present current knowledge on the factors that trigger moral distress and to guide future research by reviewing studies to explore and summarize factors that trigger moral distress in ICU nurses. Methods: The PubMed, EBSCO, and CINAHL Plus databases were searched to identify potentially relevant studies published between 2011 to 2022. Inclusion criteria: peer-reviewed studies published in English that provided results regarding factors causes or correlated to moral distress in ICU nurses. After removing 618 duplicates, 316 papers were excluded after title and abstract screening, leaving 71 articles for full-text screening. A further 54 articles were excluded as their outcomes did not include factors that caused moral distress, or were not specific to ICU nurses, so 17 studies were eventually analysed using qualitative content analysis through an inductive approach. The findings of the articles were extracted and coded independently by two authors, and data were grouped and categorized. Results: The content categories of factors contributing to ICU nurses' moral distress were organized into themes and subthemes. Four major themes were identified: Powerlessness, end-of-life care, ineffective teamwork, and personal characteristics of ICU nurses. Conclusions: This review highlights the factors that contribute to moral distress in critical care nurses, which are mainly attributable to the organizational climate and the nature of the ICU clinical environment. Descriptive and intervention studies (experimental or action research) must investigate causality between identified variables to inform management strategies to improve support for ICU nurses' coping relative to moral distress.

Critical care nurse leaders addressing moral distress: A qualitative study

BACKGROUND

Moral distress (MD) occurs when clinicians are constrained from taking what they believe to be ethically appropriate actions. When unattended, MD may result in moral injury and/or suffering. Literature surrounding how unit-based critical care nurse leaders address MD in practice is limited.

AIM

The aim of this study was to explore how ICU nurse leaders recognize and address MD among their staff.

STUDY DESIGN

Qualitative descriptive with inductive thematic analysis.

RESULTS

Five ICU nurse leaders participated in a one-time individual interview. Interview results suggest that (1) ICU nurse leaders can recognize and address MD among their staff and (2) nurse leaders experience MD themselves, which may be exacerbated by their leadership role and responsibilities.

CONCLUSIONS

Further research is needed to develop interventions aimed at addressing MD among nurse leaders and equipping nurse leaders with the skills to identify and address MD within their staff and themselves.

RELEVANCE TO CLINICAL PRACTICE

MD is an unavoidable phenomenon ICU nurse leaders are challenged with addressing in their day-to-day practice. As leaders, recognizing and addressing MD is a necessary task relating to mitigating burnout and turnover and addressing well-being among staff within the ICU.

The dual protective role of accountability: Mitigating missed nursing care and nurse moral distress in a nested diary study design

AIMS

To examine a novel moderated-mediation model, investigating whether personal accountability moderates the link between nurse workload and missed nursing care and whether missed nursing care mediates the association between workload and moral distress.

DESIGN

Nested diary study.

METHODS

Data spanning from February 2019 to February 2023 were collected from 137 nurses working in various inpatient wards in two medium-sized hospitals. Nurses reported care given to specific patients on three to five occasions across different shifts, establishing nurse-patient dyads. Validated measures of missed nursing care, personal accountability, moral distress and workload were analyzed using mixed linear models to test the nested moderated-mediation model.

RESULTS

Under high workload conditions, nurses with higher personal accountability reported lower frequencies of missed nursing care compared to those with lower personal accountability. In contrast, under low workload conditions, personal accountability did not significantly influence missed nursing care occurrences. Furthermore, the interaction between workload and personal accountability indirectly affected nurses' moral distress through missed nursing care. Specifically, higher personal accountability combined with lower missed nursing care contributed to reduced levels of moral distress among nurses.

CONCLUSION

The study highlights accountability's dual role-safeguarding against care omissions and influencing nurses' moral distress amid rising workload pressures.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Cultivating a culture of accountability within healthcare settings can serve as a protective factor against the negative effects of workload on patient care quality and nurse psychological distress, highlighting the need for organizational interventions to promote accountability among nursing staff.

IMPACT

By recognizing accountability's pivotal role, organizations can implement targeted interventions fostering accountability among nurses, including training programs focused on enhancing responsibility/ownership in care delivery and creating supportive environments prioritizing accountability to achieve positive patient outcomes.

REPORTING METHOD

The study has adhered to STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Experiences and perceptions of critical care nurses on the use of point-of-care ultrasound (POCUS) to establish peripheral venous access in patients with difficult intravenous access: a qualitative study

OBJECTIVES

This study aims to explore and describe critical care nurses' (CCNs') experiences and perceptions of using point-of-care ultrasound (POCUS) to establish peripheral intravenous access in patients with difficult intravenous access (DIVA).

DESIGN

A qualitative design with a hermeneutic approach was chosen for this study. From May to August 2022, data were collected using individual, face-to-face, and digital semistructured interviews and analysed using Braun and Clarke's reflexive thematic analysis.

SETTING

The study were conducted in six intensive care units in both Norway and Sweden.

PARTICIPANTS

Nine CCNs experienced in using point-of-care ultrasound (POCUS) to establish peripheral intravenous access in patients with DIVA were recruited.

RESULTS

Data analysis led to the construction of the overarching theme: 'POCUS simplifies a complicated procedure' based on the following five subthemes: 'Sharing the experience', 'Seeing inside the body', 'Independent in establishing difficult intravenous access', 'Using POCUS to increase action readiness', and 'Appreciating an expanded role as critical care nurses'.

CONCLUSION

Ultrasound-guided peripheral intravenous access can become a valuable skill for CCN's caring for patients with DIVA in the intensive care unit. This practice can potentially reduce patient suffering, improve patient outcomes, enable the CCN to provide high-quality care, improve action readiness, time management and job satisfaction for the nurses.

Nurses' experiences of moral distress and how it affects daily work in surgical care-a qualitative study

AIM

To describe nurses' and specialist nurses' experiences of moral distress and how it affects daily work in surgical care.

DESIGN

A qualitative descriptive study design was used.

METHODS

A qualitative study with 12 interviews with nurses and specialist nurses working in surgical care. All interviews were conducted during October and November 2022 in two hospitals in southeastern Sweden. Data were analysed using conventional qualitative content analysis.

FINDINGS

Three categories and seven subcategories generated from the data analysis. The three categories generated from the analysis were Experiences that lead to moral distress, Perceived consequences of moral distress and Strategies in case of moral distress. The results show that a lack of personnel in combination with people with complex surgical needs is the main source of moral distress. Both high demands on nurses as individuals and the teamwork are factors that generate moral distress and can have severe consequences for the safety of patients, individual nurses and future care.

CONCLUSIONS

The results show that moral distress is a problem for today's nurses and specialist nurses in surgical care. Action is necessary to prevent nurses from leaving surgical care. Prioritizing tasks is perceived as challenging for the profession, and moral distress can pose a patient safety risk.

IMPACT

Surgical care departments should design support structures for nurses, give nurses an authentic voice to express ethical concerns and allow them to practice surgical nursing in a way that does not violate their core professional values. Healthcare organizations should take this seriously and work strategically to make the nursing profession more attractive.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

Inductive process of moral distress development in viewpoints from surgical nurses: a mixed-method study

BACKGROUND

Moral distress is a multifactorial and complex phenomenon influenced by various individual, cultural, and systemic factors. This study aimed to investigate the frequency and intensity of nurses' moral distress, explore their experiences, and develop the conceptual model of risk factors of moral distress in surgical units and operating rooms.

METHOD

This is a sequential mixed-method study conducted at four teaching hospitals affiliated with the Qom University of Medical Sciences. In the first step, the moral distress of nurses in surgical units and operating rooms was investigated by a survey. The participants included nurses who worked in the operating room and surgical units. (n = 180). The data was collected by a Moral Distress Scale-Revised (MDS-R) questionnaire. In the second step, the experiences of nurses regarding risk factors of moral distress were explored using semi-structured interviews and analyzed using the conventional content analysis by Graneheim and Lundman's approach.

RESULTS

One hundred eighty nurses participated in this study. The mean total moral distress scores ranged from 12 to 221, with a mean (SD) of 116.8 (42.73). The causes of moral distress cited with the highest frequency and intensity related to the 'role of healthcare providers'. The experiences of the participants in the theme 'Inductive process of moral distress development' were categorized into three categories: 'Melting into the faulty system', 'Power and the system as distress promotors', and 'Perceived unpleasant consequences'.

CONCLUSION

The results indicated that the frequency of moral distress in operating rooms and surgical units was at a moderate level and the distress intensity of nurses was at a moderately high level. The results indicated that in the investigated system, the "inductive moral process of distress development" was continuously understood by the participants. This process was influenced by systemic and individual factors. Weak assertiveness, conservative compromise, and desensitization to unprofessionalism as individual factors were effective in causing distress. Risk factors at the systemic level led nurses to melt into the faulty system and created adverse outcomes at the individual level. The lack of systemic support and the stabilization of mobbing by powerful system members had a negative impact on the individual factors of distress development. Also, these factors directly cause negative consequences.

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

BACKGROUND

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

RESEARCH AIM

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

RESEARCH DESIGN

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

PARTICIPANT AND RESEARCH CONTEXT

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

ETHICAL CONSIDERATIONS

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

FINDINGS

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

CONCLUSIONS

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

Canadian intensive care unit nurses' responses to moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions

AIMS

To describe intensive care unit nurses' experiences of moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions.

DESIGN

Interpretive description.

METHODS

Data were collected with a purposeful sample of 40 Canadian intensive care unit nurses between May and September 2021. Nurses completed a demographic questionnaire, the Measure of Moral Distress-Healthcare Professionals survey and in-depth interviews. Quantitative data were analysed using descriptive statistics. Qualitative data were categorized and synthesized using reflexive thematic analysis and rapid qualitative analysis.

RESULTS

Half of the nurses in this sample reported moderate levels of moral distress. In response to moral distress, nurses experienced immediate and long-term effects across multiple health domains. To cope, nurses discussed varied reactions, including action, avoidance and acquiescence. Nurses provided recommendations for interventions across multiple organizations to mitigate moral distress and negative health outcomes.

CONCLUSION

Nurses reported that moral distress drove negative health outcomes and attrition in response to moral events in practice. To change these conditions of moral distress, nurses require organizational investments in interventions and cultures that prioritize the inclusion of nursing perspectives and voices.

IMPLICATIONS FOR THE PROFESSION

Nurses engage in a variety of responses to cope with moral distress. They possess valuable insights into the practice issues central to moral distress that have significant implications for all members of the healthcare teams, patients and systems. It is essential that nurses' voices be included in the development of future interventions central to the responses to moral distress.

REPORTING METHOD

This study adheres to COREQ guidelines.

IMPACT

What Problem did the Study Address? Given the known structural, systemic and environmental factors that contribute to intensive care unit nurses' experiences of moral distress, and ultimately burnout and attrition, it was important to learn about their experiences of moral distress and their recommendations for organizational mitigative interventions. Documentation of these experiences and recommendations took on a greater urgency during the context of a global health emergency, the COVID-19 pandemic, where such contextual influences on moral distress were less understood. What Were the Main Findings? Over half of the nurses reported a moderate level of moral distress. Nurses who were considering leaving nursing practice reported higher moral distress scores than those who were not considering leaving. In response to moral distress, nurses experienced a variety of outcomes across several health domains. To cope with moral distress, nurses engaged in patterns of action, avoidance and acquiescence. To change the conditions of moral distress, nurses desire organizational interventions, practices and culture changes situated in the amplification of their voices. Where and on Whom Will the Research Have an Impact on? These findings will be of interest to: (1) researchers developing and evaluating interventions that address the complex phenomenon of moral distress, (2) leaders and administrators in hospitals, and relevant healthcare and nursing organizations, and (3) nurses interested in leveraging evidence-informed recommendations to advocate for interventions to address moral distress. What Does this Paper Contribute to the Wider Global Community? This paper advances the body of scientific work on nurses' experiences of moral distress, capturing this phenomenon within the unique context of a global health emergency. Nurses' levels of moral distress using Measure of Moral Distress-Healthcare Professional survey were reported, serving as a comparator for future studies seeking to measure and evaluate intensive care unit nurses' levels of moral distress. Nurses' recommendations for mitigative interventions for moral distress have been reported, which can help inform future interventional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Care of patients undergoing withdrawal of life-sustaining treatments: an ICU nurse perspective

BACKGROUND

Intensive care unit (ICU) nurses working in South Korea report experiencing uncertainty about how to care for patients undergoing withdrawal of life-sustaining treatments (WLT). A lack of consensus on care guidelines for patients with WLT contributes to uncertainty, ambiguity, and confusion on how to act appropriately within current law and social and ethical norms. To date, little has been discussed or described about how ICU nurses construct meaning about their roles in caring for dying patients in the context of wider social issues about end-of-life care and how this meaning interacts with the ICU system structure and national law. We aimed to better understand how ICU nurses view themselves professionally and how their perceived roles are enabled and/or limited by the current healthcare system in South Korea and by social and ethical norms.

METHODS

This qualitative descriptive study was conducted using in-depth, semi-structured interviews and discourse analysis using Gee's Tools of Inquiry. Purposive sampling was used to recruit ICU nurses (n = 20) who could provide the most insightful information on caring for patients undergoing WLT in the ICU. The interviews were conducted between December 2021 and February 2022 in three university hospitals in South Korea.

RESULTS

We identified four categories of discourses: (1) both "left hanging" or feeling abandoned ICU nurses and patients undergoing WLT; (2) socially underdeveloped conversations about death and dying management; (3) attitudes of legal guardians and physicians toward the dying process of patients with WLT; and (4) provision of end-of-life care according to individual nurses' beliefs in their nursing values.

CONCLUSION

ICU nurses reported having feelings of ambiguity and confusion about their professional roles and identities in caring for dying patients undergoing WLT. This uncertainty may limit their positive contributions to a dignified dying process. We suggest that one way to move forward is for ICU administrators and physicians to respond more sensitively to ICU nurses' discourses. Additionally, social policy and healthcare system leaders should focus on issues that enable and limit the dignified end-of-life processes of patients undergoing WLT. Doing so may improve nurses' understanding of their professional roles and identities as caretakers for dying patients.

Participatory management effects on nurses' organizational support and moral distress

RESEARCH QUESTION/AIM/OBJECTIVES

Providing care for hospitalized children causes moral distress to nurses. Employee participation in discovering and solving the everyday problems of the workplace is one of the ways to hear the voices of nurses. This study aimed to evaluate the effect of participatory management programs on perceived organizational support and moral distress in pediatric nurses.

RESEARCH DESIGN

A quasi-experimental study.

PARTICIPANTS AND RESEARCH CONTEXT

The present study was conducted on 114 pediatric nurses in Iran. Data were collected using the Perceived Organizational Support Scale and the Moral Distress Scale of nurses. The intervention included implementing a participatory management program in three treatment departments that were randomly selected and it lasted 4 months. Participatory management was at the level of problem-solving with a focus on investigating, solving, and correcting issues and problems of work shifts and departments concerning the physical environment, equipment of the department, improvement of work processes, and team cooperation. In the control group, ordinary organizational approaches to problem-solving were used.

ETHICAL CONSIDERATIONS

This study was approved by the Ethics Committee of Mashhad School of Nursing and Midwifery. Informed consent was obtained from the study participants.

FINDINGS/RESULTS

Based on the results, both groups were homogenous before the intervention in terms of moral distress and perceived organizational support. The results showed that the moral distress mean scores in the intervention group decreased from 1.45 (0.52) to 1.03 (0.37) after the intervention. Also, the score of the perceived organizational support was 2.12 (1.2) increased after the intervention to 2.68 (1.10) in the intervention group.

CONCLUSIONS

It was found that the participation of nurses in the problem-solving process to solve daily workplace issues can be effective in increasing their perceived organizational support and reducing their moral distress.

Moral resilience in registered nurses: Cultural adaption and validation study

BACKGROUND

Healthcare professionals, especially professional nurses, experience various types of moral suffering due to inevitable ethical conflicts. Moral resilience is recently proposed as a resource to address moral suffering. However, there is no tool to measure moral resilience in Chinese professional nurses.

AIM

This study aimed to translate the Rushton Moral Resilience Scale (RMRS) into Chinese and evaluate the psychometric properties of the Chinese version of RMRS (Chi-RMRS).

RESEARCH DESIGN

A methodological and descriptive research design.

PARTICIPANTS AND RESEARCH CONTEXT

A convenience sample of 411 Chinese professional nurses was recruited through an online survey platform between February and March 2023.

ETHICAL CONSIDERATIONS

This study was approved by the Research Ethics Committees of the University and hospitals involved.

RESULTS

The RMRS was translated and culturally adapted into a Chinese version. Neither floor nor ceiling effects were observed. The scale-level content validity index (CVI) was 0.922 with the item-level CVIs ranging from 0.833 to 1.000. The explanatory factor analysis (EFA) generated a three-factor structure for the Chi-RMRS, and the confirmatory factor analysis (CFA) demonstrated the three-factor structure with factor loadings for each item ranging from 0.42 to 0.80. The scale-level Cronbach's α coefficient was 0.811 with each dimension ranging from 0.717 to 0.821, and composite reliability (CR) coefficient for the overall scale was 0.920, with each dimension varying from 0.739 to 0.824. The standard error of measurement (SEM) and smallest detectable change (SDC) were 3.522 and 9.763, respectively.

DISCUSSION

The Chi-RMRS is able to measure moral resilience of Chinese professional nurses, and has good validity and reliability. It can be used in research and practice to determine the level of moral resilience, thus helping nursing managers to monitor the status of Chinese professional nurses, then develop interventions to maintain the well-being of professional nurses and to ensure quality of care.

Development of ethical conflict scale for nurses in extraordinary circumstances and psychometric testing

AIM

The aim of this study was to develop and psychometrically test the Ethical Conflict Scale for Nurses in Extraordinary Circumstances (ECSNEC).

DESIGN

This study is designed to develop and validate an instrument.

METHODS

There are four basic steps in the development process of ECSNEC: (1) establishment of the conceptual framework, (2) creation of the item pool, (3) preliminary evaluation and (4) psychometric evaluation. The data were gathered from 519 nurses who worked in two different hospitals operating in Istanbul between June 2022 and October 2022.

RESULTS

The scale had good content validity. The exploratory factor analysis revealed a three-factor construct which explained 47.31% of the total variance in the measured variable. The corresponding construct was confirmed by the confirmatory factor analysis. The Cronbach's alpha coefficients were greater than .60 for all dimensions. The test-retest reliability coefficient value of the scale was 0.90.

CONCLUSION

ECSNEC is a valid and reliable tool to determine the ethical conflict experienced by nurses in extraordinary circumstances.

IMPACT

The established scale allows the identification of factors influencing the ethical challenges nurses face in extraordinary circumstances. Thus, policies can be developed to prevent such ethical conflicts.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

'Telling them "that's what it says in the guidance" didn't feel good enough': moral distress during the pandemic in UK public health professionals

BACKGROUND

The study aimed to identify the causes of moral distress in public health professionals associated with the COVID-19 pandemic, and the potential ways of avoiding or mitigating the distress.

METHODS

The survey was distributed to all members of the UK Faculty of Public Health between 14 December 2021 and 23 February 2022. Conventional qualitative content analysis was conducted to explore the situations in which moral distress arises, the moral judgments that led to distress and the proposed ways to address moral distress.

RESULTS

A total of 629 responses were received from respondents broadly representative of the public health professional workforce. The main situations causing moral distress were national policy, guidance and law; public health advice; and workplace environments. Moral distress was precipitated by judgments about having caused injury, being unable to do good, dishonest communications and unjust prioritization. The need to improve guidance, communication and preparedness was recognized, though there was disagreement over how to achieve this. There were consistent calls for more subsidiarity, moral development and support and freedom to voice concerns.

CONCLUSIONS

The causes of moral distress in public health are distinct from other healthcare professions. Important proposals for addressing moral distress associated with the COVID-19 pandemic have been voiced by public health professionals themselves.

Navigating moral and ethical dilemmas in digital transformation processes within healthcare organizations

Objective

Healthcare systems around the world face a turbulent and unstable global and local ecosystem that changes daily and impacts the healthcare organization and its workforce. This challenging environment, coupled with economic pressures, is forcing healthcare systems to change and adopt strategic and technological processes to adapt to change at all levels of the system (macro-holistic multi-systemic, mezzo-organizational, and micro-personal).

Methods

In this study, through 32 in-depth, semi-structured interviews with healthcare professionals working in public general hospitals in central Israel, we examined, mapped, and highlighted the conflicts and moral dilemmas they have faced in recent years, alongside the processes of strategic, technological, and digital changes that the healthcare system has undergone.

Results

The findings from both a categorical-deductive approach and an inductive approach analysis reveals four main themes: innovation paradox, quality and treatment conflict, information and knowledge conflict, and personal needs and values. The themes and sub-themes are sorted across the three levels of the healthcare system.

Conclusions

These findings represent a wide range of conflicts and moral dilemmas that arise from the implementation of strategic change and digital transformation, adding to the already numerous ethical issues and moral dilemmas in healthcare and bioethics that are associated with three levels of the system. These challenges and moral conflicts can be barriers to implementing the necessary changes, as well as challenging individuals' internal values, potentially leading to burnout and moral distress. Given the importance of this issue and the intensification of change processes over the next few years, it is up to the management and key stakeholders to implement these processes in a way that addresses the conflicts and challenges that health professionals face. Minimizing the level of challenges and moral distress in the health sector will be to the benefit of the system, its workers, and the patients it serves.

The experiences of intensive care nurses coping with ethical conflict: a qualitative descriptive study

BACKGROUND

The critical conditions and life risk scenarios make intensive care nurses susceptible to ethical conflict. Negative consequences were recognized at both the individual level and the professional level which highly compromised the patient care and nurses' well-being. Therefore, ethical conflict has become a major concern in nursing practice. However, the experience of coping with ethical conflict among intensive care nurses remains unclear.

AIMS

This study aims to explore the experience of intensive care nurses coping with ethical conflict in China.

METHODS

From December 2021 to February 2022, in- depth interviews with 15 intensive care nurses from five intensive care units in a tertiary general hospital in China was performed using purposive sampling. An inductive thematic analysis approach was used to analyze the data. We applied the consolidated criteria for reporting qualitative research for this study.

RESULTS

Two distinctive themes were found: detachment and engagement, which contained four subthemes: ignoring ethical problems in the workplace, seeking ways to express emotions, perspective-taking, and identifying positive assets. Theses coping strategies demonstrated an ongoing process with different essential features.

CONCLUSION

This study provides a new insight into the experience of intensive care nurses coping with ethical conflict in clinical nursing. Intensive care nurses demonstrated differential experience of coping with ethical conflict including problem-focused, emotion-focused and meaning-making strategies. These findings have implications for policymakers and nursing administrators to develop ethical education and training and supportive environment for intensive care nurses to tackle this issue.

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.

Knowledge mobilization in critical care and the evolving communication role of nurses

BACKGROUND

The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes.

AIMS

The purpose of this study was to explore how knowledge/evidence is acquired, shared, and applied in the Critical Care (CC) environment for staff and patients/family members.

STUDY DESIGN

A qualitative approach was used, consisting of semi-structured interviews and focus groups. Data analysis was conducted using an iterative thematic approach.

RESULTS

Data collected prior to the COVID-19 pandemic from United Kingdom (UK) critical care workers (N = 46), patients, and family members (N = 21) identified four communication roles performed by the nursing staff: team member; diplomat; translator and friend.

CONCLUSIONS

It was evident that without suitable training and support, the stresses and demands placed upon the nurses could lead to disenfranchisement and burnout.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant and timely given the impact of the pandemic, highlighting the need for accessible and alternate communication strategies to support nurses by reducing stress, moral distress and increasing psychological safety. Improved communication can provide tailored information for staff and patients/family improving the CC experience for all.

Developing a behaviour rubric for the practical model of ethical behaviour for clinical nursing

AIM

The present study aimed to develop an ethical behaviour rubric for nurses and evaluate its reliability and validity.

METHOD

This study was to designed to construct a rubric and evaluate the reliability and validity. The ethical behaviour rubric was distributed to 241 nurses and 154 were completed and returned. The intra-rater and inter-rater reliability were evaluated by intraclass correlation coefficient (ICC) for all 10 items on the ethical behaviour rubric, and the internal consistency reliability was evaluated using Cronbach's α. Construct validity was tested with explanatory factor analysis, and criterion validity was tested using the known-groups method.

RESULTS

Intra-rater reliability had a high interrater agreement (ICC = 0.9), and inter-rater reliability had a high interrater agreement (ICC = 0.84). The Cronbach's α coefficient was 0.96. There was a linear correlation between the number of years of nursing experience and rubric scores p < 0.001. Exploratory factor analysis revealed 10 items loading on four factors. The result of factor analysis is that Cronbach's α was 0.93 for the first factor, 0.83 for the second factor, 0.91 for the third factor, and 0.77 for the fourth factor.

CONCLUSIONS

Our rubric was found to be a valid and reliable tool for the assessment of ethical behaviour among nurses in Japan.

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

BACKGROUND

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

RESEARCH AIMS

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

RESEARCH DESIGN

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

PARTICIPANTS

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

ETHICAL CONSIDERATIONS

IRB approval was obtained.

RESULTS

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

CONCLUSIONS

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

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BACKGROUND

Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied.

OBJECTIVE

The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia.

METHODS

An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated.

RESULTS

A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement.

CONCLUSION

The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

The Nurses' Second Victim Syndrome and Moral Distress

BACKGROUND

The increasing prevalence of moral distress in the stressful environment of the intensive care unit (ICU) provides grounds for nursing error and endangers patients' health, safety, and even life. One of the most important reasons for this distress is the treatment team's second victim syndrome (SVS), especially nurses, following errors in the treatment system.

OBJECTIVES

The present study aimed to determine the relationship between moral distress and SVS in ICUs.

RESEARCH DESIGN

This cross-sectional study involved a sample size of 96 ICU nurses working in hospitals affiliated with Tehran University of Medical Sciences, Iran, in the 2021-2022 period, who were selected via a simple random sampling method. Data were collected using the Demographic Questionnaire, the second victim experience and support tool (SVEST) and Moral Distress Scale-Revised (MDS-R). Descriptive statistics (percentage, frequency, mean, and SD) and analytical tests (Spearman correlation coefficient test, independent t-test, and ANOVA) were employed for data analysis.

PARTICIPANTS AND RESEARCH CONTEXT

This study used a sample size of 96 intensive care unit nurses working in hospitals affiliated to Tehran University of Medical Sciences selected by simple random sampling.

ETHICAL CONSIDERATIONS

The study obtained research ethics approval, and all participants were informed of the voluntary and anonymous nature of their participation.

FINDINGS

The results showed that 59.4% of nurses suffered a low level of moral distress, and 40.6% suffered from a moderate level of moral distress. The SVS score of 86.5% of the nurses was moderate. There was no significant and direct correlation between moral distress and SVS in nurses; however, there was a significant and inverse correlation between the moral distress intensity and SVS (p = 0.011).

CONCLUSION

Despite no significant correlation between moral distress and SVS, these variables were at moderate levels. Accordingly, it is suggested to provide a proper ground for expressing morally stressful situations, counseling and training strategies to deal with moral distress, creating support resources for those suffering from SVS, and implementing empowerment programs.

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.

Moral distress and injury in the public health professional workforce during the COVID-19 pandemic

BACKGROUND

There is growing concern about moral distress and injury associated with the COVID-19 pandemic in healthcare professions. This study aimed to quantify the nature, frequency, severity and duration of the problem in the public health professional workforce.

METHODS

Between 14 December 2021 and 23 February 2022, Faculty of Public Health (FPH) members were surveyed about their experiences of moral distress before and during the pandemic.

RESULTS

In total, 629 FPH members responded, of which, 405 (64%; 95% confidence interval [95%CI] = 61-68%) reported one or more experience of moral distress associated with their own action (or inaction), and 163 (26%; 95%CI = 23-29%) reported experiencing moral distress associated with a colleague's or organization's action (or inaction) since the start of the pandemic. The majority reported moral distress being more frequent during the pandemic and that the effects endured for over a week. In total, 56 respondents (9% of total sample, 14% of those with moral distress), reported moral injury severe enough to require time off work and/or therapeutic help.

CONCLUSIONS

Moral distress and injury are significant problems in the UK public health professional workforce, exacerbated by the COVID-19 pandemic. There is urgent need to understand the causes and potential options for its prevention, amelioration and care.

The relationship between teamwork, moral sensitivity, and missed nursing care in intensive care unit nurses

BACKGROUND

Teamwork, moral sensitivity, and missed nursing care are important healthcare challenges for Intensive Care Unit (ICU) nurses and the existence of a relationship between these variables can be useful for developing better care improvement strategies. This study aimed to determine the relationship between teamwork, moral sensitivity, and missed nursing care in ICU nurses.

METHODS

This is a descriptive cross-sectional study conducted on a total of 200 ICU nurses working at teaching hospitals affiliated to Semnan and Shahroud Universities of Medical Sciences, Semnan, Iran in 2022. Sampling was conducted using the census method. Data collection was conducted using a demographic checklist, the TeamSTEPPS Team Perception Questionnaire (T-TPQ), Lützén Moral Sensitivity Questionnaire (L-MSQ), and Kalisch and Williams Missed Nursing Care (MISSCARE) Survey. The examination of the relationship between the three variables was conducted using Pearson's correlation coefficient and multiple regression analysis.

RESULTS

The mean and standard deviation of teamwork, moral sensitivity, and missed nursing care was 3.47 ± 0.69, 64.19 ± 13.43, and 55.04 ± 34.10, respectively. The variable of teamwork had a significant positive relationship with moral sensitivity (p < .001) and a significant negative relationship with missed nursing care (p < .001). Teamwork was also a positive predictor of moral sensitivity (p < .001) and a negative predictor of missed nursing care (p < .001). The clinical experience of ICU nurses was a positive predictor of teamwork (p = .01) and a negative predictor of missed nursing care (p = .001). The age of ICU nurses was a positive predictor of moral sensitivity (p = .001) and a negative predictor of missed nursing care (p = .008).

CONCLUSION

The findings showed that a higher level of teamwork was associated with increased moral sensitivity and reduced missed nursing care among ICU nurses. Therefore, focusing on planning interventions on teamwork improvement can lead ICU nurses to improve moral sensitivity, lower missed nursing care, and promote the quality of patient care.

The relationship between the ethical attitudes and holistic competence levels of intensive care nurses: A cross-sectional study

BACKGROUND

Intensive care units are directly associated with the competency level of nurses and are units where ethical problems are frequently experienced. This research aims to determine the relationship between intensive care nurses' ethical attitudes and holistic competence levels.

METHODS

This study was conducted as a cross-sectional design using self-report questionnaires distributed to 131 intensive care nurses in Turkey. The data of the study were collected with the "Nurses Information Form," "Holistic Nursing Competence Scale" and "Ethical Attitude Scale for Nursing Care".

RESULTS

The total mean score of the Holistic Nursing Competence of the nurses was 6.89±0.95. Holistic Nursing Competence level was significantly lower for those who had experienced less than one year in the profession, and it was higher for those who worked in the emergency intensive care unit and the nurses whose clinics had 21 and above nurses. The total mean score of the nurses' ethics attitude toward nursing care was 59.36±29.09. Ethical Attitude for Nursing Care was significantly lower for those who had a master's degree, and the nurses whose clinics had 21 and above nurses scored higher. There was a weak and negative correlation between the nurses' Holistic Nursing Competence Scale and the total mean score of the Ethical Attitude Scale for Nursing Care. The ethical attitude was predicted in 13.2% of the Holistic Nursing Competence of nurses.

CONCLUSIONS

It was concluded that nurses' holistic competence levels were high, their ethical attitudes were negative, and there was a weak negative correlation between their holistic competence levels and their ethical attitudes toward care.

Moral Breakdowns and Ethical Dilemmas of Perioperative Nurses during COVID-19: COREQ-Compliant Study

(1) Background: The COVID-19 pandemic has led to an increase in the complexity of caregiving, resulting in challenging situations for perioperative nurses. These situations have prompted nurses to assess their personal and professional lives. The aim of this study was to explore the experiences of perioperative nurses during the first wave of the COVID-19 pandemic, with a specific focus on analyzing moral breakdowns and ethical dilemmas triggered by this situation. (2) Methods: A qualitative design guided by a hermeneutical approach was employed. Semi-structured interviews were conducted with 24 perioperative nurses. The interviews were transcribed and thematically analysed following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. (3) Results: The findings revealed three main categories and ten subcategories. These categories included the context in which moral breakdowns emerged, the ethical dilemmas triggered by these breakdowns, and the consequences of facing these dilemmas. (4) Conclusions: During the first wave of COVID-19, perioperative nurses encountered moral and ethical challenges, referred to as moral breakdowns, in critical settings. These challenges presented significant obstacles and negatively impacted professional responsibility and well-being. Future studies should focus on identifying ethical dilemmas during critical periods and developing strategies to enhance collaboration among colleagues and provide comprehensive support.

Supporting ethical end-of-life care during pandemic: Palliative care team perspectives

BACKGROUND

Italy was the first European country to be involved with the COVID-19 pandemic. As a result, many healthcare professionals were deployed and suddenly faced end-of-life care management and its challenges.

AIMS

To understand the experiences of palliative care professionals deployed in supporting emergency and critical care staff during the COVID-19 first and second pandemic waves.

RESEARCH DESIGN

A qualitative descriptive design was adopted, and in-depth interviews were used to investigate and analyse participants' perceptions and points of view.

PARTICIPANTS AND RESEARCH CONTEXT

Twenty-four healthcare professionals (physicians, nurses, psychologists, physiotherapists, and spiritual support) from the most affected areas of Italy were recruited via the Italian society of palliative care and researchers' network.

ETHICAL CONSIDERATIONS

The University Institutional Board granted ethical approval. Participants gave written informed consent and agreed to be video-recorded.

FINDINGS

The overarching theme highlighted participants' experience supporting health professionals to negotiate ethical complexity in end-of-life care. Crucial topics that emerged within themes were: training emergency department professionals on ethical dimensions of palliative and end-of-life care, preserving dying patients' dignity and developing ethical competence in managing end-of-life care.

CONCLUSIONS

Our study showed palliative care teams' challenges in supporting health professionals' ethical awareness in emergencies. However, while they highlighted their concerns in dealing with the emergency staff's lack of ethical perspectives, they also reported the positive impact of an ethically-informed palliative care approach. Lastly, this study illuminates how palliative care professionals' clinical and ethical competence might have assisted a cultural change in caring for dying patients during COVID-19 and future emergencies.

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

BACKGROUND

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

LOCAL PROBLEM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Moral Distress, Organizational Climate, and the Risk of Burnout Among Physician Assistants in Oncology

PURPOSE

Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs).

METHODS

A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory.

RESULTS

One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout.

CONCLUSION

This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

Understanding the Relationships Between Health Care Providers' Moral Distress and Patients' Quality of Death

Introduction: Moral distress is a commonly recognized phenomenon among health care providers; however, the experience of moral distress by staff caring for patients who die during an acute care hospital stay has not been previously examined. It also remains unclear how the quality of a death may impact moral distress among these providers. Objectives: We sought to understand levels of moral distress experienced by intern physicians and nurses who provided care during a patient's final 48 hours of life, and how the perceived quality of death impacted moral distress. Materials and Methods: We utilized a mixed-method prospective cohort design, surveying nurses and interns following inpatient hospital deaths at an academic safety-net hospital in the United States. Participants completed surveys and answered open-ended questions to evaluate moral distress and the quality of the patient's death. Results: A total of 126 surveys were sent to nurses and interns caring for 35 patients who died, with 46 surveys completed. Overall moderate-to-high levels of moral distress were identified among participants, and we found that higher levels of moral distress correlated with lower perceived quality of death. We identified five themes in our qualitative analysis highlighting the challenges nurses and interns face in end-of-life care, including the following: poor communication, unexpected deaths, patient suffering, resource limitations, and failure to prioritize a patient's wishes or best interests. Conclusions: Nurses and interns experience moderate-to-high levels of moral distress when caring for dying patients. Lower quality of end-of-life care is associated with higher levels of moral distress.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study

Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions.

OBJECTIVES

To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress.

DESIGN

Interview-based qualitative study using inductive thematic analysis.

SETTING AND PARTICIPANTS

Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians.

RESULTS

Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians.

CONCLUSIONS AND RELEVANCE

An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Experiences of patient advocacy among nurses working in a resource constrained emergency department in Ghana

BACKGROUND

Patient advocacy at the emergency department is stressful and cumbersome as a result of the increasing patient-to-nurse ratio and high patient turnovers. It is also unclear what patient advocacy entails and the experiences of patient advocacy in a resource-constrained emergency department. This is significant because advocacy underpins the care provided in the emergency department.

AIM

The primary aim of this study is to explore the experiences and underpinning factors that influence patient advocacy among nurses working in a resource constrained emergency department.

METHODS

A descriptive qualitative study was conducted among 15 purposively sampled ED nurses working at a resource-constrained secondary-level hospital facility. Study participants were individually interviewed via a recorded telephone conversation, after which the interviews were transcribed verbatim and inductively analyzed using the content analysis approach. The study participants described patient advocacy, situations in which they advocated for patients, the factors that motivated them and the challenges they encountered practicing patient advocacy.

RESULTS

Three major themes generated from the study included: "stories of advocacy", "motivating" factors and "challenging" factors. ED nurses understood patient advocacy and also advocated for patients in various instances. There were factors such as personal upbringing, professional training and religious training that motivated them and they were challenged by negative inter-professional experiences, patient and relatives' attitudes and healthcare system factors.

CONCLUSION

Participants understood patient advocacy and incorporated it into daily nursing care. Unsuccessful advocacy causes disappointment and frustrations. There were no documented guidelines on patient advocacy.

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.

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.

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

Objective

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

Research Design

Qualitative phenomenological design with a focus group approach.

Methods

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

Results

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

Conclusion

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

Moral Distress, Health and Intention to Leave: Critical Care Nurses' Perceptions During COVID-19 Pandemic

Introduction

Moral distress increases the risk that critical care nurses will lose the ability to provide quality nursing care.

Aims

To describe person-related conditions and perceptions of moral distress, health and intention to leave among critical care nurses in intensive care units, and to examine the relationship between person-related conditions, moral distress, health and intention to leave.

Method

Cross-sectional, with 220 critical care nurses in 15 Swedish ICUs, and data gathered via a self-reported questionnaire.

Results

Highest moral distress scores were reported in futile care and poor teamwork and 21% reported entertaining an intention to leave. Self-reported health was lower than before the COVID-19 pandemic and 4.1% reported pronounced exhaustion disorder. Self-reported health, reduced capacity to tolerate demands under time pressure, emotional instability or irritability, physical weakness, or being more easily fatigued and with decreased well-being were factors that had a relationship with futile care. Sleeping problems and intention to leave had a relationship with poor teamwork.

Conclusions

Different strategies are needed to reduce moral distress and the leadership is crucial for managing crises such as the COVID-19 pandemic.

Critical Care Nurses' Adherence to Ethical Codes and Its Association with Spiritual Well-Being and Moral Sensitivity

Background

Adherence to ethical codes is a major pillar of nursing care that is affected by various factors. Identifying these factors can lead to better ethical performance. The present study was conducted to determine critical care nurses' adherence to ethical codes and its association with spiritual well-being (SWB) and moral sensitivity (MS).

Methods

In this descriptive-correlational study, data were collected using the moral sensitivity questionnaire (MSQ) by Lützén et al., Paloutzian and Ellison's spiritual well-being scale (SWBS), and the adherence to ethical codes questionnaire. The study was conducted on 298 nurses working in critical care units of hospitals affiliated with Shiraz University of Medical Sciences in southern Iran in 2019. This study was examined and approved by the Ethics Committee of Shiraz University of Medical Sciences.

Results

The majority of the participants were female (76.2%) and single (60.1%), with a mean age of 30.69 ± 5.74 years. The mean scores of adherence to ethical codes, SWB, and MS were 64.06 (good), 91.94 (moderate), and 134.08 (moderate), respectively. Adherence to ethical codes had a positive correlation with the total score of SWB (P < 0.001, r = 0.25) and MS (P < 0.001, r = 0.27). A positive correlation was also observed between MS and SWB (P < 0.001, r = 0.41). Meanwhile, MS (β = 0.21) had a greater effect than SWB (β = 0.157) on adherence to ethical codes.

Conclusion

Critical care nurses showed a good adherence to ethical codes. MS and SWB also positively affected their adherence to ethical codes. Nursing managers can use these findings to devise plans for the promotion of MS and SWB in nurses and thus help improve their ethical performance.

Identifying Sources of Moral Distress Amongst Critical Care Staff During the Covid-19 Pandemic Using a Naturalistic Inquiry

Introduction

Moral distress can have a significant impact on the mental health and well-being of practitioners. Causes of moral distress in critical care have been identified as futile treatment, conflict between family members and staff, lack of resources, and dysfunctional teams.

Objectives

This study explores the sources of moral distress during the COVID-19 pandemic and the meaning that staff attached to these events. The study aims to examine whether the sources of moral distress are similar, or different, to those that commonly occur in critical care departments.

Methods

Naturalistic inquiry using semi-structured individual interviews with 17 participants drawn from nursing ( n = 12), medicine ( n = 3), and the allied health professions ( n = 2). The interviews were recorded and transcribed verbatim. The transcripts were analyzed using reflexive thematic analysis.

Results

The results suggested that while there were some similar sources of moral distress including caring for dying patients and not being able to provide the usual standard of care, the nature of the disease trajectory and frequency of death had a significant impact. In addition, the researchers found that providing care which was counter-intuitive, concerns about the risks to the staff and their families and the additional burdens associated with leading teams in times of uncertainty were identified as sources of moral distress.

Conclusion

This study explored the potential sources of moral distress during the pandemic and the meaning that practitioners attached to their experiences. There were some similarities with the sources of moral distress in critical care which occur outside of a pandemic. However, the frequency and intensity of the experiences are likely to be different during a pandemic, with staff describing high volumes of deaths without family members present. In addition, new sources of moral distress related to uncertainty, counter-intuitive care and concerns about personal and family risk of infection were identified.

Moral Distress in Canadian Intensivists: A Complex Interplay of Contextual and Relational Factors

BACKGROUND

Health-care professionals experience moral distress when they cannot act based on their moral beliefs because of perceived constraints. Moral distress prevalence is high among critical care (ICU) clinicians, but varies significantly between and within professions.

RESEARCH QUESTION

How can the interindividual variability in moral distress of Canadian ICU physicians be explained to inform future system-based interventions?

STUDY DESIGN

And Methods: We analyzed 135 free-text comments written by 83 of the 225 ICU physicians who participated in an online cross-sectional wellness survey. An interdisciplinary team of five investigators completed the thematic analysis of anonymized survey comments according to published guidelines.

RESULTS

Physicians identified contextual and relational factors that contributed to moral distress and work-related stress. Combined sources of distress created high work-related demands that were not always matched by equally high resources or mitigated by work-related rewards. An imbalance between demands and rewards could lead to undesirable individual and collective consequences.

INTERPRETATION

Moral distress is experienced variably by ICU physicians and is linked to contextual and relational factors. Future studies should evaluate modifiable factors such as team interactions and the role of professional rewards as mitigators of distress to bring new insights into strategies to improve ICU clinician wellness and patient care.

Moral distress, moral courage, and career identity among nurses: A cross-sectional study

Background

The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity.

Objectives

To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral distress and career identity among nurses.

Design

A quantitative, cross-sectional study.

Methods

A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses’ Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement.

Ethical consideration

Research ethics approval was obtained from the researcher’s university and hospital where this study was conducted prior to data collection.

Findings

Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity ( β = −0.230 to −0.163, p < 0.01).

Discussion

The findings reveal a relationship between moral distress, moral courage, and career identity among nurses.

Conclusion

By paying attention to nurses’ moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses.

Palliative care practice and moral distress during COVID-19 pandemic (PEOpLE-C19 study): a national, cross-sectional study in intensive care units in the Czech Republic

Background

Providing palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors.

Methods

Between 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress.

Results

In total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% (n = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% (n = 113) of nurses and 71.6% of (n = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057–3.252; p = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128–0.430; p < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection.

Conclusions

HCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate.

Trial registration: NCT04910243.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04066-1.