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

Nursing students' experience of moral distress in clinical settings: A phenomenological study

AIM

To explore nursing students' moral distress (MD) experiences in clinical settings.

DESIGN

An interpretative phenomenological analysis (IPA) design was employed.

METHODS

Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method.

RESULTS

Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity.

CONCLUSION

Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Moral distress among critical care nurses before and during the COVID-19 pandemic: A systematic review

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interventions to Reduce Nurses' Moral Distress in the Intensive Care Unit: An Integrative Review

BACKGROUND

Critical care nurses experience moral distress, the phenomenon of knowing the "right" thing to do but being unable to do so, at high rates; this contributes to attrition and has severe mental health impacts on nurses.

OBJECTIVE

The purpose of this integrative review was to determine if interventions to reduce moral distress have an effect on intensive care unit (ICU) nurses' moral distress levels.

METHODS

Three databases were searched, PubMed, APA PsycNet, and CINAHL, using the keywords "moral distress" AND nurs* AND reduc* AND ("intensive care" OR "critical care" OR ICU). Only experimental studies involving adult ICU nurses were included for a total of 6 studies.

RESULTS

Interventions fell into 3 categories: (1) educational interventions, (2) interventions to enhance the ICU environment, and (3) interventions to help nurses cope. Two studies detailing educational interventions demonstrated some reduction in moral distress. One study aimed to improve the ICU environment and showed some statistically significant reduction in moral distress. All 6 studies included some focus on coping, and 2 showed statistically significant reductions in moral distress.

DISCUSSION

Only a few studies have been conducted examining this issue. These studies had severe limitations, such as small sample sizes, attrition, and inadequate control groups. There were also few statistically significant results. These interventions should be reexamined using larger sample sizes, and other interventions should also be trialed. COVID-19 may have had a significant impact on this issue, and interventions may need to be refocused in the wake of the pandemic.

Moral Distress Events and Emotional Trajectories in Nursing Narratives during the COVID-19 Pandemic

The COVID-19 pandemic produced several ethical challenges for nurses, impacting their mental health and moral distress. In the moral distress model the categories of events related to moral distress are: constraint, dilemma, uncertainty, conflict, and tension, each one related to different emotions. This study explored moral events’ memories and emotions in narratives of a sample of 43 Italian nurses who worked during the COVID-19 pandemic. We constructed an ad-hoc narrative interview asking nurses to narrate the memory, and the associated emotion, of an event in which they felt they could not do the right thing for the patient. We conducted a theory-driven analysis, using the categories proposed by the literature, identifying the main emotion for each category. Results show that 36 memories of events are representative of moral distress; among these, 7 are representative of none of the categories considered, and we categorized them as moral compromise. The main emotional trajectories are powerlessness, worthlessness, anger, sadness, guilt, and helplessness. From a clinical psychological point of view, our findings highlight the narration of the memories of moral events as a tool to use in the ethical sense-making of critical experiences, in order to promote well-being and moral resilience among nurses in emergency situations.

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

BACKGROUND

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

AIM

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

RESULTS

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

CONCLUSION

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

Moral distress interventions: An integrative literature review

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Effective interventions for reducing moral distress in critical care nurses

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, as well as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses.

Investigating the impact of written emotion disclosure on the level of occupational stress among intensive care nurses

Objective

The present study was conducted with the aim of determining the impact of rewriting pleasant events on the level of occupational stress in Intensive Care Unit (ICU) nurses.

Methods

This is a quasi-experimental research conducted on nurses working in the intensive care units of Imam Khomeini and Golestan hospitals in Ahvaz, from July to November 2021. Seventy-six nurses were selected based on the inclusion criteria, and were then randomly assigned to the intervention and the control groups. The nurses' demographic information form and the Expanded Nursing Stress Scale (ENSS) were used to collect data. In the intervention group, the technique of rewriting pleasant events was used for 8 weeks, at least once a week. The data was analyzed with SPSS V20.

Results

No significant difference in the demographic characteristics was observed between the intervention and the control groups (p > 0.05). The pre-intervention occupational stress of the nurses in the intervention and the control groups were reported to be 173.86 ± 26.75 and 173.05 ± 24.47, respectively, showing no statistically significant difference (p = 0.89). After the intervention, the occupational stress scores were 134.21 ± 16.09 and 172.36 ± 24.33, respectively, showing a significant difference between the two groups (p < 0.001).

Conclusion

Considering the impact of rewriting pleasant events on the level of occupational stress of ICU nurses, it is recommended that nursing managers and nurses plan training programs for nurses in this area, and encourage other nurses to do so, too. It is also suggested to implement this intervention on the nurses of other wards as well.

Psychosocial and psychological interventions' effectiveness among nurses in intensive care units caring for pediatric patients: A systematic review and meta-analysis

OBJECTIVE

This review aimed to evaluate the effectiveness of psychosocial and psychological interventions in nurses among intensive care units caring for pediatric patients.

METHODS

A literature search was performed in PubMed, EMBASE, CINAHL databases, using preferred reporting items for systematic reviews and meta-analysis guidelines. Study design, population characteristics, contents of the programs, measured outcomes, and results were systematically reviewed from 8 selected studies. To estimate the effect size, a meta-analysis of the studies was performed using the RevMan 5.3 program. The effect size used was the standardized mean difference.

RESULTS

Of 1,630 studies identified, 4 met the inclusion criteria, and 3 studies were used to estimate the effect size of psychosocial and psychological interventions. The primary outcome variable of these studies was stress. The effect of the intervention program on stress was also found to have no effect in individual studies, and the overall effect size was not statistically significant (standardized mean difference = -0.06; 95% confidence interval: -0.33, 0.20; Z = 0.48, p = 0.630). However, according to the individual literature included in this study, after the stress management program was applied as a group, a significant stress reduction was shown in the experimental group (p = 0.021).

CONCLUSIONS

These results show that psychosocial and psychological interventions were effective in stress management by a group approach. Therefore, it is necessary to develop psychosocial support interventions for stress management of nurses among intensive care units caring for pediatric patients more diversely.

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

Background

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

Methods

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

Results

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

Conclusions

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

Recommendations for navigating the experiences of moral distress: A scoping review

BACKGROUND

Moral distress is a complex ethical phenomenon that occurs when one is not able to act according to their moral judgement. Consequences of moral distress negatively impact nurses, patient care, and the healthcare system. There is limited evidence on specific approaches to prepare nurses to manage these ethical situations.

AIM

The aim of this scoping review is to identify moral distress interventions for nurses who provide direct patient care, identify gaps in the current moral distress research, and determine areas of focus for future research on this topic.

METHODS

We employed the framework outlined by Levac, Colquhoun, and O'Brien and Arksey and O'Malley to conduct a scoping review. These steps included the: identification of the research question, identification of relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. We appraised the quality of included studies using the Mixed Methods Appraisal Tool.

RESULTS

We identified 5206 articles from the selected databases. Once duplicates were removed, two independent reviewers each screened 4043 title and abstracts. We included 554 articles for full-text screening, with 10 studies included based on inclusion and exclusion criteria. Study designs included before-after studies (n = 4), randomized control trials (n = 3), concurrent mixed-methods studies (n = 2), and one controlled before-after study. All studies were conducted in acute care settings. In four studies, interventions focused on informing nurses on moral distress. Two interventions focused on increasing the nurses' reflexivity on their workplace experiences. One intervention included formal clinical mentoring and clinical ethics support through interprofessional rounds. Two studies utilized a multicomponent intervention. The overall moral distress scores significantly decreased after intervention implementation in three included studies. Three additional studies showed significant differences in specific survey item scores (e.g., "provision of less-than-optimal care" and "caring for patients they did not feel qualified to care for"), as compared to overall scores, after intervention implementation. In 70% of studies the amount of quality criteria met were 60% or higher according to the Mixed Methods Appraisal Tool.

CONCLUSION

Our review is the first to synthesize intervention studies pertaining to moral distress among nurses. The findings of this review demonstrate that there is no clear pattern regarding which strategies consistently minimize the effects of moral distress among nurses. Future interventions should be tested more broadly by increasing the sample size, assessing length of intervention in relation to moral distress scores, expanding the interventions to other units and institutions, and including other healthcare professionals. Tweetable abstract: We reviewed interventions to help nurses with moral distress. Findings show no clear pattern of strategies to minimize their moral distress.

Interventions to reduce moral distress in clinicians working in intensive care: A systematic review

OBJECTIVE

To evaluate the effectiveness of interventions to mitigate the harmful effects of moral distress experienced by nursing and medical clinicians working in the intensive care setting.

DESIGN

Eligible studies were identified from searches of PubMed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus. Included studies were published prior to 20 August 2020.

RESULTS

Twelve studies were included in this review comprising three randomised controlled trials, seven quasi-randomised trials and two observational studies. Nine studies reported interventions targeting only nurses while three included both nurses and doctors. The types of interventions identified included: moral empowerment programs, end-of-life educational programs, reflective exercises through individual narrative writing or group reflective debriefing, multidisciplinary case debriefing meetings integrated into clinical practice and moral resiliency training. Due to the overall low methodological quality and high risk of bias, no single intervention may be considered efficacious in managing moral distress.

CONCLUSIONS

There is weak evidence that some currently available interventions reduce the moral distress experienced by intensive care health care providers. Larger randomised trials involving all intensive healthcare clinicians are required to evaluate multifaceted interventions.

Interventions to mitigate moral distress: A systematic review of the literature

BACKGROUND

Moral distress is a pervasive phenomenon that can negatively impact healthcare professionals and has been well studied in nursing populations. Much of the evidence suggests that it is associated with intention to leave high acuity areas and the profession. Despite the increasing amounts of research to explore the causes and effects of moral distress, there is limited research on interventions that mitigate the negative effects of moral distress.

OBJECTIVES

The aims of this systematic review were to: (a) identify and examine interventions developed to address moral distress experienced by health care professionals (b) examine the quality of the research methods and (c) report on the efficacy of these interventions.

DESIGN

We conducted a systematic review of interventional studies developed to mitigate moral distress.

DATA SOURCE

Medline, Embase, PsycINFO, CINAHL and Cochrane were searched for relevant studies (July 2019- September 2019). Additional bioethics databases and reference lists were also hand-searched.

REVIEW METHODS

The first author reviewed all retrieved titles and abstracts with a low tolerance for borderline papers based on inclusion and exclusion criteria, and those papers were reviewed and discussed by all authors to determine inclusion. Quality appraisal was conducted on the included studies using narrative synthesis to compare the findings. Data were extracted and compared by all authors and then reviewed by the first author for consistency.

RESULTS

Sixteen papers were included for full text review and the following interventions identified: educational interventions of varying length and breadth; facilitated discussions ranging from 30 to 60 minutes; specialist consultation services; an intervention bundle; multidisciplinary rounds; self-reflection and narrative writing. Researchers reported statistically significant reductions in moral distress using pre and post surveys, including one mixed methods program evaluation (n=7). The qualitative program evaluation provided participant quotations to suggest their program was beneficial. There were no statistically significant findings in the other studies (n=8). All studies had limitations in design and methodology presenting significant threats to validity.

CONCLUSION

Designing rigorous research studies that measure the impact of interventions aimed at mitigating moral distress continues to be challenging. The primary reason being that moral distress is a subjective ethical phenomenon with a number of different causes and effects. This calls for interventions that are flexible and sensitive to individual's needs. To build an evidence-base, interventions should also be measurable and research methods need to be scientifically rigorous. To achieve rigor and innovation, researchers should clearly justify their methodological choices. Tweetable abstract: Interventions to mitigate moral distress: a systematic review of the literature. Educational interventions offer a promising direction but more research is needed.

Nurses' Participation in Limited Resuscitation: Gray Areas in End of Life Decision-Making

Historically nurses have lacked significant input in end-of-life decision-making, despite being an integral part of care. Nurses experience negative feelings and moral conflict when forced to aggressively deliver care to patients at the EOL. As a result, nurses participate in slow codes, described as a limited resuscitation effort with no intended benefit of patient survival. The purpose of this study was to explore and understand the process nurses followed when making decisions about participation in limited resuscitation. Five core categories emerged that describe this theory: (1) recognition of patient and family values at the EOL; (2) stretching time and reluctance in decision-making; (3) harm and suffering caused by the physical components of CPR; (4) nurse's emotional and moral response to delivering aggressive care, and; (5) choosing limited resuscitation with or without a physician order. Several factors in end-of-life disputes contribute to negative feelings and moral distress driving some nurses to perform slow codes in order to preserve their own moral conflict, while other nurses refrain unless specifically ordered by physicians to provide limited care through tailored orders.

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.