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Beadle ES, Walecka A, Sangam AV, Moorhouse J, Winter M, Munro Wild H, Trivedi D, Casarin A. Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies. PLoS One 2024; 19:e0303013. [PMID: 38935754 PMCID: PMC11210881 DOI: 10.1371/journal.pone.0303013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 04/17/2024] [Indexed: 06/29/2024] Open
Abstract
OBJECTIVE At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions. METHODS A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic. RESULTS Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change. CONCLUSION This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.
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Affiliation(s)
- Emily S. Beadle
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | | | - Amy V. Sangam
- Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | | | - Matthew Winter
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Helen Munro Wild
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Daksha Trivedi
- Centre for Research in Public Health and Community Care, School of Health and Social Work, The University of Hertfordshire, Hatfield, United Kingdom
| | - Annalisa Casarin
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Jazzaa Alruwaili A, Jamil Alkuwaisi M, Jazzaa Alruwaili E. The moral distress and resilience among emergency nurses in Arar city: Saudi Arabia. Int Emerg Nurs 2024; 74:101447. [PMID: 38688205 DOI: 10.1016/j.ienj.2024.101447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Understanding moral distress and resilience is crucial for supporting the well-being of emergency nursing staff and improving patient care. However, there is limited research specifically examining moral distress and resilience among emergency nursing staff in ARAR city hospitals. AIMS This study aims to examine moral distress and resilience levels among emergency nursing staff in ARAR city hospitals. Specifically, the study seeks to determine the correlation between moral distress and resilience among emergency nursing staff and examine differences in the levels of moral distress and resilience among different demographic and occupational characteristics. METHODS A cross-sectional study design was employed, involving a non-probability stratified sample of emergency nursing staff from two hospitals in ARAR city. The participants completed a Brazilian Moral Distress Scale in Nurses (MDSN-BR) and Rushton Moral Resilience Scale in Nurses (RMRS). Statistical analyses, including descriptive statistics and one-way- ANOVA, were conducted to analyze the data. RESULTS The study found that emergency nursing had a moderate level of moral distress, with a mean frequency of 2.70 (SD = 1.02) and a mean intensity of 2.79 (SD = 1.04). The overall self-reported moral resilience was also moderate, with a mean score of 2.48 (SD = 0.77). Significant positive correlations were observed between resilience and both moral distress frequency (r = 0.48, p = 0.001) and intensity (r = 0.48, p = 0.001). Educational levels and nursing positions were associated with variations in moral distress and resilience. Postgraduate diploma emergency nursing reported the highest levels of moral distress frequency (3.12, SD = 1.14) and intensity (3.21, SD = 1.16). A bachelor's degree in nursing exhibited higher levels of personal integrity (3.06, SD = 0.87), while a master's degree in nursing showed higher levels of moral efficacy (2.88, SD = 1.09). Head nurses experienced higher levels of moral distress compared to other positions (3.08, SD = 1.37 for frequency; 3.18, SD = 1.29 for intensity). CONCLUSION The study revealed that emergency nursing experienced relatively moderate levels of moral distress, which could be attributed to insufficient multidisciplinary teams and unprepared actions. The findings also highlighted moderate levels of moral resilience, particularly in relational integrity. Educational levels and nursing positions were found to influence moral distress and resilience. These results underscore the need for targeted interventions to support the well-being of emergency nurses and enhance ethical decision-making.
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Affiliation(s)
| | | | - Eman Jazzaa Alruwaili
- Prince Abdullah bin Abdulaziz bin Musaed Specialized Dental Center, Arar, Saudi Arabia.
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King N, Lewis EG, Kinnison T, Langridge A, Civai C, May SA, Cardwell JM. Mental health of veterinary nurses and student veterinary nurses: A scoping review. Vet Rec 2024; 194:e4091. [PMID: 38622978 DOI: 10.1002/vetr.4091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/22/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Research has shown that veterinarians around the world are at high risk of mental health problems, but far less research has examined the mental health of veterinary nurses (VNs) and student veterinary nurses (SVNs). This scoping review aimed to map existing evidence on this topic and identify knowledge gaps. METHODS Literature searches of MEDLINE, PsycINFO, PubMed, Web of Science and Google Scholar were conducted, and a structured screening and selection procedure was applied. To be included, studies had to be peer reviewed, report relevant results specific to VNs and/or SVNs, and provide descriptive statistics if using quantitative methods. RESULTS Of the 2118 publications identified, only 13 journal articles met the inclusion criteria. The findings were summarised in five categories: mental health and wellbeing, burnout, stress, compassion fatigue and moral distress. While the findings of five of the studies suggested that some VNs and SVNs experienced some form of poor mental health, these studies lacked generalisability or transferability for multiple reasons. There was also inconsistency and ambiguity in the interpretation of findings, as well as incompatible or oversimplified definitions of mental health problems. LIMITATIONS Our review excluded grey literature, such as reports, theses and conference presentations, as a preliminary search found very little empirical research on VNs' and SVNs' mental health in this type of publication. CONCLUSIONS More research is needed to address the gaps in the existing evidence supporting our understanding of VN and SVN mental health. This should establish baseline measures and include comparisons with other occupational and national populations.
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Affiliation(s)
- Naomi King
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hatfield, UK
| | - Elisa G Lewis
- Division of Psychology, School of Applied Sciences, London South Bank University, London, UK
| | - Tierney Kinnison
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - Alison Langridge
- The College of Animal Welfare & CAW Business School, Godmanchester, UK
| | - Claudia Civai
- Division of Psychology, School of Applied Sciences, London South Bank University, London, UK
| | - Stephen Anthony May
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - Jacqueline M Cardwell
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hatfield, UK
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Wilson MA, Shay A, Harris JI, Faller N, Usset TJ, Simmons A. Moral Distress and Moral Injury in Military Healthcare Clinicians: A Scoping Review. AJPM FOCUS 2024; 3:100173. [PMID: 38304024 PMCID: PMC10832382 DOI: 10.1016/j.focus.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Introduction Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member. Methods A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies. Results A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis. Discussion This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.
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Affiliation(s)
- Melissa A. Wilson
- U.S. Air Force Research Laboratory, Dayton, Ohio
- College of Health, Education and Human Services Department of Nursing, Wright State University, Dayton, Ohio
| | - Amy Shay
- School of Nursing, Indiana University, Indianapolis, Indiana
| | | | | | - Timothy J. Usset
- Division of Health Policy & Management, University of Minnesota, Minneapolis, Minnesota
| | - Angela Simmons
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Grace PJ, Peter E, Lachman VD, Johnson NL, Kenny DJ, Wocial LD. Professional responsibility, nurses, and conscientious objection: A framework for ethical evaluation. Nurs Ethics 2024; 31:243-255. [PMID: 37420337 PMCID: PMC11181723 DOI: 10.1177/09697330231180749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
Conscientious objections (CO) can be disruptive in a variety of ways and may disadvantage patients and colleagues who must step-in to assume care. Nevertheless, nurses have a right and responsibility to object to participation in interventions that would seriously harm their sense of integrity. This is an ethical problem of balancing risks and responsibilities related to patient care. Here we explore the problem and propose a nonlinear framework for exploring the authenticity of a claim of CO from the perspective of the nurse and of those who must evaluate such claims. We synthesized the framework using Rest's Four Component Model of moral reasoning along with tenets of the International Council of Nursing's (ICN) Code of Ethics for Nurses and insights from relevant ethics and nursing ethics literature. The resulting framework facilitates evaluating potential consequences of a given CO for all involved. We propose that the framework can also serve as an aid for nurse educators as they prepare students for practice. Gaining clarity about the sense in which the concept of conscience provides a defensible foundation for objecting to legally, or otherwise ethically, permissible actions, in any given case is critical to arriving at an ethical and reasonable plan of action.
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Affiliation(s)
- Pamela J Grace
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | | | - Norah L Johnson
- College of Nursing, Marquette University, Milwaukee, WI, USA
| | - Deborah J Kenny
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Lucia D Wocial
- John J Lynch MD Center for Ethics, Medstar Washington Hospital Center, Washington, DC, USA
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Alexander D, Quirke M, Greene J, Cassidy L, Hilliard C, Brenner M. The role of bioethics services in paediatric intensive care units: a qualitative descriptive study. BMC Med Ethics 2024; 25:20. [PMID: 38374022 PMCID: PMC10877773 DOI: 10.1186/s12910-024-01017-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 02/13/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND There is considerable variation in the functionality of bioethical services in different institutions and countries for children in hospital, despite new challenges due to increasing technology supports for children with serious illness and medical complexity. We aimed to understand how bioethics services address bioethical concerns that are increasingly encountered in paediatric intensive care. METHODS A qualitative descriptive design was used to describe clinician's perspectives on the functionality of clinical bioethics services for paediatric intensive care units. Clinicians who were members of formal or informal clinical bioethics groups, or who were closely involved with the process of working through ethically challenging decisions, were interviewed. Interviews took place online. Resulting transcripts were analysed using thematic analysis. RESULTS From 33 interviews, we identified four themes that described the functionality of bioethics services when a child requires technology to sustain life: striving for consensus; the importance of guidelines; a structure that facilitates a time-sensitive and relevant response; and strong leadership and teamwork. CONCLUSIONS Clinical bioethics services have the potential to expand their role due to the challenges brought by advancing medical technology and the increasing options it brings for treatment. Further work is needed to identify where and how bioethics services can evolve and adapt to fully address the needs of the decision-makers in PICU.
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Affiliation(s)
- Denise Alexander
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Mary Quirke
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Jo Greene
- Maynooth University, Maynooth, Ireland
| | - Lorna Cassidy
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | | | - Maria Brenner
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
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Tomura M. Psychiatric nurses' experience of moral distress: Its relationship with empowerment and coping. Nurs Ethics 2023; 30:1095-1113. [PMID: 37226471 DOI: 10.1177/09697330231153915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored. RESEARCH AIM The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses' experience of moral distress, and strategies for coping with moral distress. RESEARCH DESIGN A descriptive cross-sectional correlational study. PARTICIPANTS AND RESEARCH CONTEXT A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted. ETHICAL CONSIDERATIONS The study was approved by the institutional review board at the author's affiliated university. FINDINGS Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses' moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively. CONCLUSIONS In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance.
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Affiliation(s)
- Michiko Tomura
- Psychiatric Nursing, Japanese Red Cross Hiroshima College of Nursing, Hatsukaichi, Japan
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Arbe Montoya AI, Matthew SM, Jarden A, Hazel SJ, McArthur ML. The moral deliberation pathway in veterinary practice: a qualitative study. Vet Rec 2023; 193:e3173. [PMID: 37455249 DOI: 10.1002/vetr.3173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Veterinarians may face various ethical decisions and potential moral conflicts in clinical practice. The ethical decision-making process often leads to a satisfying resolution. However, when such a process is accompanied by a perceived inability to act according to a person's values, it can lead to psychological distress that characterises moral distress. Theoretical models in professions such as nursing attempt to explain the evolution of moral conflict into moral distress. In veterinary professionals, a model has been proposed to explain this pathway (the moral deliberation pathway). However, empirical data are still lacking on whether veterinary clinicians experience a moral deliberation pathway as hypothesised. METHODS Using thematic analysis, this qualitative study investigates veterinary clinicians' experiences with moral distress and aims to explain the moral deliberation pathway in these veterinarians. RESULTS The results suggest that veterinarians' experiences with moral distress follow a deliberation process that can be explained by the proposed moral deliberation pathway. Experiencing a moral conflict leads to moral stress, then either to moral distress or resolution into moral comfort. LIMITATIONS Self-selection of participants and possible recollection bias may have biased the findings. CONCLUSIONS The empirical data provided by this study can inform future research and intervention strategies to identify, measure and manage moral distress in the veterinary context.
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Affiliation(s)
- Alejandra I Arbe Montoya
- School of Animal and Veterinary Science, University of Adelaide, Roseworthy, South Australia, Australia
| | - Susan M Matthew
- College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Aaron Jarden
- Centre for Wellbeing Science, Melbourne Graduate School of Education, University of Melbourne, Victoria, Australia
| | - Susan J Hazel
- School of Animal and Veterinary Science, University of Adelaide, Roseworthy, South Australia, Australia
| | - Michelle L McArthur
- School of Animal and Veterinary Science, University of Adelaide, Roseworthy, South Australia, Australia
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Manookian A, Nadali J, Ghiyasvandian S, Weaver K, Haghani S, Divani A. Spiritual care competence, moral distress and job satisfaction among Iranian oncology nurses. Int J Palliat Nurs 2023; 29:487-497. [PMID: 37862158 DOI: 10.12968/ijpn.2023.29.10.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
BACKGROUND Nurses have a crucial role in identifying spiritual needs and providing spiritual care to patients living with cancer. AIM This study evaluated Iranian oncology nurses' spiritual care competence and its relationship with job satisfaction and moral distress. METHOD This cross-sectional study was conducted on 280 Iranian oncology nurses in 2020 using four questionnaires: demographic questionnaires, the Spiritual Care Competence Questionnaire (SCCQ), the Minnesota Job Satisfaction Questionnaire (MSQ) and the nurses' Moral Distress Questionnaire (MDS-R). FINDINGS The mean scores indicated a medium to high Spiritual Care Competence (SCC), mild to moderate moral distress and high job satisfaction. There was a positive correlation between SCC and external job satisfaction (r=184, p<0.05) and a negative correlation between SCC and moral distress (r=-0.356, p<0.05). CONCLUSIONS SCC diminishes with decreasing external job satisfaction and increasing moral distress. To improve the SCC of nurses working with patients living with cancer, it is recommended that nursing managers and policymakers revise the organisational policies to tackle the obstacles and consider the related factors to provide an ethical climate, implement quality spiritual care and increase job satisfaction.
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Affiliation(s)
- Arpi Manookian
- Associate Professor of Nursing, USERN CARE (TUMS) Office, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Javad Nadali
- Clinical Instructor of Nursing, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Iran
| | - Shahrzad Ghiyasvandian
- Professor of Nursing, Medical-Surgical Nursing Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Kathryn Weaver
- Honorary Research Professor, Faculty of Nursing, University of New Brunswick, Fredericton, Canada
| | - Shima Haghani
- Biostatistical Supervisor, Biostatistics Department, Iran University of Medical Sciences, Iran
| | - Anahita Divani
- Oncology Nurse Practitioner, Cancer Institute of Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran
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Palmer JA, Mccullough M, Wormwood J, Soylemez Wiener R, Mesfin N, Still M, Xu CS, Linsky AM. Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19. PLoS One 2023; 18:e0291542. [PMID: 37713379 PMCID: PMC10503769 DOI: 10.1371/journal.pone.0291542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.
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Affiliation(s)
- Jennifer A. Palmer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | - Megan Mccullough
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Medical Center, Bedford, Massachusetts, United States of America
- University of Massachusetts, Lowell, Massachusetts, United States of America
| | - Jolie Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Medical Center, Bedford, Massachusetts, United States of America
- University of New Hampshire, Durham, New Hampshire, United States of America
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Nathan Mesfin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Michael Still
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Chris S. Xu
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, United States of America
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Kubitza J, Große G, Schütte-Nütgen K, Frick E. Influence of spirituality on moral distress and resilience in critical care staff: A scoping review. Intensive Crit Care Nurs 2023; 76:103377. [PMID: 36669436 PMCID: PMC9850638 DOI: 10.1016/j.iccn.2022.103377] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The Covid 19 pandemic has created a situation in which critical care staff experience moral distress. For reducing moral distress, resources such as spirituality can be used. The aim of this scoping review is to explore whether spirituality mitigates the moral distress of critical care staff and strengthens their resilience. The spiritual resources will be identified and the ability of the staff to use spiritual resources will be explored. METHODOLOGY A scoping review of studies reporting on the association between spirituality, moral distress, and resilience. Qualitative and quantitative studies from 2020 that examined critical care staff are included. This scoping review used the five-step framework proposed by Arksey and O'Malley and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for scoping reviews. The literature searches were conducted in 12 databases. RESULTS 13 studies met inclusion criteria. Critical care staff declaring themselves as spiritual have a higher risk of moral distress and are often not able to use spiritual resources on their own. For effective use of spiritual resources to reduce moral distress, staff need to be skilled in the practice of spirituality with the aim to find inner peace, focus on the positive, and regain a sense of purpose in the work. CONCLUSION Spirituality does not automatically help the critical care staff to cope with moral distress and strengthen resilience. Institutions need to create conditions in which the critical care staff are supported to use their spiritual resources. IMPLICATION FOR CLINICAL PRACTICE Institutions need to involve staff more in the design, implementation, and delivery of spiritual interventions to minimise moral distress. Further research is necessary to examine the impact of critical care staff's demographic characteristics on their spirituality, moral distress, and resilience.
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Affiliation(s)
- Jenny Kubitza
- University Hospital rechts der Isar, Department of Psychosomatic Medicine and Psychotherapy, Professorship of Spiritual Care and Psychosomatic Health, Technical University of Munich, Kaulbachstraße 22a, Munich 80539, Germany,Corresponding author
| | - Greta Große
- Ludwig-Maximilians-Universität München, Faculty of Medicine, Munich, Germany
| | - Katharina Schütte-Nütgen
- University Medical Center Freiburg, Clinic of Palliative Medicine, Robert-Koch-Straße 3, Freiburg 79106, Germany
| | - Eckhard Frick
- University Hospital rechts der Isar, Department of Psychosomatic Medicine and Psychotherapy, Professorship of Spiritual Care and Psychosomatic Health, Technical University of Munich, Kaulbachstraße 22a, Munich 80539, Germany
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12
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Deschenes S, Scott SD, Kunyk D. Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations. HEC Forum 2023:10.1007/s10730-023-09506-1. [PMID: 37140806 PMCID: PMC10158695 DOI: 10.1007/s10730-023-09506-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/05/2023]
Abstract
In pediatric critical care, nurses are the primary caregivers for critically ill children and are particularly vulnerable to moral distress. There is limited evidence on what approaches are effective to minimize moral distress among these nurses. To identify intervention attributes that critical care nurses with moral distress histories deem important to develop a moral distress intervention. We used a qualitative description approach. Participants were recruited using purposive sampling between October 2020 to May 2021 from pediatric critical care units in a western Canadian province. We conducted individual semi-structured interviews via Zoom. A total of 10 registered nurses participated in the study. Four main themes were identified: (1) "I'm sorry, there's nothing else": increasing supports for patients and families; (2) "someone will commit suicide": improving supports for nurses: (3) "Everyone needs to be heard": improving patient care communication; and (4) "I didn't see it coming": providing education to mitigate moral distress. Most participants stated they wanted an intervention to improve communication among the healthcare team and noted changes to unit practices that could decrease moral distress. This is the first study that asks nurses what is needed to minimize their moral distress. Although there are multiple strategies in place to help nurses with difficult aspects of their work, additional strategies are needed to help nurses experiencing moral distress. Moving the research focus from identifying moral distress towards developing effective interventions is needed. Identifying what nurses need is critical to develop effective moral distress interventions.
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Affiliation(s)
- Sadie Deschenes
- Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB, T6G 1C9, Canada.
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB, T6G 1C9, Canada
| | - Diane Kunyk
- Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB, T6G 1C9, Canada
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13
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Voth Schrag RJ, Fantus S, Leat S, Childress S, Wood L. Experiencing Moral Distress Within the Intimate Partner Violence & Sexual Assault Workforce. JOURNAL OF FAMILY VIOLENCE 2023:1-13. [PMID: 37358973 PMCID: PMC10132954 DOI: 10.1007/s10896-023-00567-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 06/28/2023]
Abstract
Purpose Moral distress (MD) refers to the psychological disequilibrium that emerges when institutional policies and/or practices conflict with an individual's professional values and ethics. MD has been interrogated frequently in health care and ancillary medical settings, and has been identified as a critical barrier to enhanced organizational climate and patient care. However, little work has investigated experiences of MD among members of the intimate partner violence (IPV) and sexual violence (SV) workforce. Methods This study investigates MD in a sample of IPV and SV service providers via secondary analysis of 33 qualitative interviews conducted with service providers in the summer and fall of 2020 as the COVID-19 pandemic response was unfolding. Results Qualitative content analysis revealed multiple overlapping vectors of MD experienced by IPV and SV service providers related to institutional resource constraints, providers working beyond their capacity and/or competency, shifting responsibilities within service agencies creating burdens among staff; and breakdowns in communication. Impacts of these experiences at individual, organizational, and client levels were identified by participants. Conculsions The study uncovers the need for further investigation of MD as a framework within the IPV/SV field, as well as potential lessons from similar service settings which could support IPV and SV agencies in addressing staff experiences of MD.
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Affiliation(s)
- Rachel J. Voth Schrag
- The University of Texas at Arlington School of Social Work, 211 S. Cooper, Arlington, TX 76019 USA
| | - Sophia Fantus
- The University of Texas at Arlington School of Social Work, 211 S. Cooper, Arlington, TX 76019 USA
| | | | - Saltanat Childress
- The University of Texas at Arlington School of Social Work, 211 S. Cooper, Arlington, TX 76019 USA
| | - Leila Wood
- The University of Texas Medical Branch at Galveston, Galveston, USA
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14
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Guariglia L, Terrenato I, Iacorossi L, D’Antonio G, Ieraci S, Torelli S, Nazzicone F, Petrone F, Caruso A. Moral Distress in Oncology: A Descriptive Study of Healthcare Professionals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20085560. [PMID: 37107841 PMCID: PMC10139085 DOI: 10.3390/ijerph20085560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND The oncology setting is characterized by various complexities, and healthcare professionals may experience stressful conditions associated with ethical decisions during daily clinical practice. Moral distress (MD) is a condition of distress that is generated when an individual would like to take action in line with their ethical beliefs but in conflict with the healthcare facility's customs and/or organization. This study aims to describe the MD of oncology health professionals in different care settings. METHODS Descriptive quantitative study was conducted in the Operating Units of the Istituti Fisioterapici Ospitalieri in Rome between January and March 2022. The investigated sample consisted of the medical and nursing staff on duty at the facility, who were given a questionnaire through a web survey. Besides a brief sociodemographic form, the MD Scale-Revised questionnaire was used for data collection. RESULTS The sample consisted of nurses (51%) and physicians (49%), predominantly working in surgeries (48%), and having 20-30 years of service (30%). MD was higher among healthcare professionals, in medicine than that ing in corporate organizations, surgeries, or outpatient clinics (p = 0.007). It was not related to the profession (p = 0.163), gender (p = 0.103), or years of service (p = 0.610). CONCLUSIONS This paper outlines the prevalence of MD in care settings and describes its relationship with profession, gender, and seniority. There is no patient care without the care of health professionals: knowing and fighting MD improves the safety of the treatments provided and the quality perceived by patients.
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Affiliation(s)
- Lara Guariglia
- Psychology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Irene Terrenato
- Biostatistics & Bioinformatics, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | - Laura Iacorossi
- Nursing Research Unit IFO, IRCCS Regina Elena, National Cancer Institute, 00144 Rome, Italy
- Correspondence:
| | - Giovanna D’Antonio
- Psychology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Sonia Ieraci
- Psychology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Stefania Torelli
- Psychology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Fabiola Nazzicone
- Nursing, Technical, Rehabilitation, Assistance, and Research Direction IFO, IRCCS Regina Elena, National Cancer Institute, 00144 Rome, Italy
| | - Fabrizio Petrone
- Nursing, Technical, Rehabilitation, Assistance, and Research Direction IFO, IRCCS Regina Elena, National Cancer Institute, 00144 Rome, Italy
| | - Anita Caruso
- Psychology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
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15
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Kok N, Zegers M, Hoedemaekers C, van Gurp J. Moral Distress: The Context of Measurement. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:71-74. [PMID: 37011357 DOI: 10.1080/15265161.2023.2186514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Niek Kok
- Radboud University Medical Center
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16
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Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study. Crit Care Explor 2023; 5:e0879. [PMID: 36895887 PMCID: PMC9990831 DOI: 10.1097/cce.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
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.
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Cooke S, Booth R, Jackson K. Moral distress in critical care nursing practice: A concept analysis. Nurs Forum 2022; 57:1478-1483. [PMID: 35962765 DOI: 10.1111/nuf.12786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/17/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
AIM To provide a critical analysis of the concept of moral distress (MD) in critical care (CC) nursing. BACKGROUND Despite extensive inquiry pertaining to the legitimacy of MD within nursing discourse, some authors still question its relevancy to the profession. However, amid the global COVID-19 pandemic, MD is generating a significant amount of discussion anew, warranting the further exploration of the concept within CC nursing to provide clarity and expand on the definition. DESIGN Rodger's Evolutionary Concept Analysis method was used to guide this analysis. METHODS Related terms, attributes, antecedents, and consequences of MD were identified using current literature. RESULTS The results of this analysis demonstrate strong congruence between the attributes, antecedents, and negative consequences pertaining to MD. However, a new theme has emerged from this review of the contemporary literature, highlighting the potential unexpected positive outcomes perceived by nurses who experience MD, including the provision of better care, increased levels of empathy, and enhanced opportunities for ethical reflection.
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Affiliation(s)
- Samantha Cooke
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Kimberley Jackson
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
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18
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Faraco MM, Gelbcke FL, Brehmer LCDF, Ramos FRS, Schneider DG, Silveira LR. Moral distress and moral resilience of nurse managers. Nurs Ethics 2022; 29:1253-1265. [PMID: 35549481 DOI: 10.1177/09697330221085770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience. AIM The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil. RESEARCH DESIGN The research design is the qualitative study with discursive textual analysis. PARTICIPANTS AND RESEARCH CONTEXT : 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions. ETHICAL CONSIDERATIONS The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity. FINDINGS Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation. CONCLUSION From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience.
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Gustavsson ME, Juth N, Arnberg FK, von Schreeb J. Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders. Confl Health 2022; 16:24. [PMID: 35527276 PMCID: PMC9079207 DOI: 10.1186/s13031-022-00456-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges. Methods Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis. Results We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate. Conclusion The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00456-y.
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Moral Distress in Healthcare Providers Who Take Care of Critical Pediatric Patients throughout Italy-Cultural Adaptation and Validation of the Italian Pediatric Instrument. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073880. [PMID: 35409562 PMCID: PMC8997869 DOI: 10.3390/ijerph19073880] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
Background: Although Moral Distress (MD) is a matter of concern within the Pediatric Intensive Care Unit (PICU), there is no validated Italian instrument for measuring the phenomenon in nurses and physicians who care for pediatric patients in Intensive Care. The authors of the Italian Moral Distress Scale-Revised (Italian MDS-R), validated for the adult setting, in 2017, invited further research to evaluate the generalizability of the scale to clinicians working in other fields. Our study aims to reduce this knowledge gap by developing and validating the pediatric version of the Italian MDS-R. Methods: We evaluated the new instrument for construct validity, then we administered it in a multicenter, web-based survey that involved healthcare providers of three PICUs and three adult ICUs admitting children in northern, central, and southern Italy. Finally, we tested it for internal consistency, confirmatory factorial validity, convergent validity, and differences between groups analysis. Results: The 14-item, three-factor model best fit the data. The scale showed good reliability (a = 0.87). Still, it did not correlate with the Emotional Exhaustion and Depersonalization sub-scales of the Maslach Burnout Inventory (MBI) or with the 2-item Connor-Davidson Resilience Scale (CD-RISC 2) or the Satisfaction with Life Scale (SWLS). A mild correlation was found between the Italian Pediatric MDS-R score and intention to resign from the job. No correlation was found between MD and years of experience. Females, nurses, and clinicians who cared for COVID-19 patients had a higher MD score. Conclusions: The Italian Pediatric MDS-R is a valid and reliable instrument for measuring MD among Italian health workers who care for critically ill children. Further research would be helpful in better investigating its applicability to the heterogeneous scenario of Italian Pediatric Critical Care Medicine.
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21
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Buckley L, Berta W, Cleverley K, Widger K. Exploring Pediatric Nurses' Perspectives on Their Work Environment, Work Attitudes, and Experience of Burnout: What Really Matters? Front Pediatr 2022; 10:851001. [PMID: 35372172 PMCID: PMC8968655 DOI: 10.3389/fped.2022.851001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pediatric nurses care for some of the most vulnerable patients in our healthcare system and are vulnerable to the impact of the stress of their work on their well-being. Burnout is a potential response to chronic interpersonal stressors and a negative work outcome linked to personal and professional consequences. A thorough understanding of the experience and factors associated with burnout in this population is an important part of developing interventions to mitigate or prevent this workplace outcome. Therefore, our study objectives were to: (1) explain and expand our understanding of pediatric critical care nurses experience of burnout in relation to their work environment and work engagement; (2) provide recommendations for nursing administrators to improve nurses' work environment, work attitudes, and work outcomes. Methods A convenience sample of pediatric critical care nurses from a large pediatric quaternary care hospital in Ontario, Canada were invited to participate in this second phase of a sequential explanatory mixed-methods study. Semi-structured interviews were conducted, with and main themes and subthemes distilled through the method of interpretive description. Results A total of 18 PICU/CCCU/NICU nurses participated. Derived themes included the experience and identification of burnout, including its prevalence and elusiveness. Their experiences of quality of work-life included themes such as compensation, emotional support at work, respect, their professional identity, and spill over into home life. They discussed components of work engagement, including the work itself, investment into their growth and development, and the meaning of their work. The self-care subthemes included the importance of preparation and recovery, and the use of physical and mental separation as a preservation strategy. The participants' recommendations for strategies to mitigate burnout were also summarized. Conclusion Burnout is a complex and regularly occurring experience for pediatric critical care nurses. Although the experience may be difficult to self-identify, the impacts on the individuals are profound. Further research and organizational support are needed to test practical and evidence-based interventions to improve the well-being of this population.
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Affiliation(s)
- Laura Buckley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kristin Cleverley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
- The Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
- The Hospital for Sick Children, Toronto, ON, Canada
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22
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Birkholz L, Kutschar P, Kundt FS, Beil-Hildebrand M. Ethical decision-making confidence scale for nurse leaders: Psychometric evaluation. Nurs Ethics 2022; 29:988-1002. [PMID: 35230887 PMCID: PMC9289993 DOI: 10.1177/09697330211065847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Ethical decision-making confidence develops from clinical expertise and is a core competency for nurse leaders. No tool exists to measure confidence levels in nurse leaders based upon an ethical decision-making framework. Aims The objective of this research was to compare ethical decision-making among nurse leaders in the U.S. and three German-speaking countries in Europe by developing and testing a newly constructed Ethical Decision-Making Confidence (EDMC) scale. Methods The cross-sectional survey included 18 theory-derived questions on ethical decision-making confidence which were used to develop the scale. Participants A convenience sample of nurse leaders from the U.S. and three German-speaking countries in Europe who self-identified as holding a leadership position. Ethical Considerations Ethical approval was given by the IRB Board of a U.S. university. Participation in the survey implied voluntary consent. Results The scale’s item structure dimensionality and subscale’s reliability were analyzed and compared between nurse leaders from all four countries. A principal component analysis (PCA) produced a 15-item bi-dimensional EDMC scale yielding a skill-related (9-item) and a behavior-related (6-item) confidence dimension. EDMC subscales showed good-to-excellent internal consistency. In both subscales, U.S. nurse leaders rated their mean EDMC score higher than their German-speaking counterparts in Europe. Discussion This exploratory study is the first of its kind to focus on nurse leaders’ confidence regarding ethical decision-making in an international context. An overarching factor structure was identified, which is shared by the two samples of nurse leaders and to examine (sub)scales’ psychometric properties. Conclusion This newly developed scale is an effective tool for measuring ethical decision-making confidence in nurse leaders. The promising results of this study should be replicated to ensure validity and reliability of the EDMC scale measuring skill-related and behavior-related concepts and include nurse leaders from various cultural, social, and demographic groups.
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Affiliation(s)
- Lorri Birkholz
- 575981Chatham University School of Nursing, Pittsburgh, PA, USA
| | - Patrick Kutschar
- Institute of Nursing Science and Practice, 31507Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Firuzan Sari Kundt
- Institute of Nursing Science and Practice, 31507Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Margitta Beil-Hildebrand
- Institute of Nursing Science and Practice, 31507Paracelsus Medical University Salzburg, Salzburg, Austria
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Abstract
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.
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Wilson CA, Metwally H, Heavner S, Kennedy AB, Britt TW. Chronicling moral distress among healthcare providers during the COVID-19 pandemic: A longitudinal analysis of mental health strain, burnout, and maladaptive coping behaviours. Int J Ment Health Nurs 2022; 31:111-127. [PMID: 34644443 PMCID: PMC8653372 DOI: 10.1111/inm.12942] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
The COVID-19 pandemic has presented many novel situations that have amplified the presence of moral distress in healthcare. With limited resources to protect themselves against the virus and strict safety regulations that alter the way they work, healthcare providers have felt forced to engage in work behaviours that conflicted with their professional and personal sense of right and wrong. Although many providers have experienced moral distress while being physically in the workplace, others suffered while at home. Some healthcare providers worked in facilities that were unable to open during the pandemic due to restrictions, which could contribute to a sense of powerlessness and guilt. The current study assessed whether the ability to see patients each week impacted the relationship between an employee's moral distress and their mental health strain, burnout, and maladaptive coping. A total of 378 healthcare providers responded to weekly surveys over the course of 7 months (April 2020-December 2020). Hierarchical linear modeling techniques were used to examine the study variables over time. Results showed that moral distress predicted an individual's mental health strain and burnout, even after controlling for the prior week. However, moral distress was not a significant predictor of maladaptive coping. Interestingly, there was not a significant difference between the average ratings of moral distress between those who were able, and those who were not able to see patients, meaning that both groups experienced symptoms of moral distress. However, cross-level moderation results indicated that the ability to see patients magnified the relationships between moral distress and mental health strain and burnout over time. Implications of the results and recommendations for how moral distress should be addressed among healthcare providers are discussed.
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Affiliation(s)
| | | | | | - Ann Blair Kennedy
- University of South Carolina School of Medicine Greenville Campus, Greenville, South Carolina, USA
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25
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Zeydi AE, Ghazanfari MJ, Suhonen R, Adib-Hajbaghery M, Karkhah S. Effective interventions for reducing moral distress in critical care nurses. Nurs Ethics 2022; 29:1047-1065. [PMID: 35081833 DOI: 10.1177/09697330211062982] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Amir Emami Zeydi
- Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, 108890Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Javad Ghazanfari
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, 48462Kashan University of Medical Sciences, Kashan, Iran
| | - Riitta Suhonen
- Department of Nursing Science, 8058University of Turku, Turku, Finland.,Welfare Services Division, 8058Turku University Hospital and City of Turku, Turku, Finland
| | - Mohsen Adib-Hajbaghery
- Trauma Nursing Research Center, 48462Kashan University of Medical Sciences, Kashan, Iran
| | - Samad Karkhah
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, 37554Guilan University of Medical Sciences, Rasht, Iran.,Social Determinants of Health Research Center (SDHRC), 37554Guilan University of Medical Sciences, Rasht, Iran.,Burn and Regenerative Medicine Research Center, 37554Guilan University of Medical Sciences, Rasht, Iran
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Dodek PM, Jameson K, Chevalier JM. New approach to assessing and addressing moral distress in intensive care unit personnel: a case study. Can J Anaesth 2022; 69:1240-1247. [PMID: 35997856 PMCID: PMC9499887 DOI: 10.1007/s12630-022-02307-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To test a new approach to address moral distress in intensive care unit (ICU) personnel. METHODS Using principles of participatory action research, we developed an eight-step moral conflict assessment (MCA) that guides participants in describing the behaviour that they have to implement, the effects this has on them, their current coping strategies, their values in conflict, any other concerns related to the situation, what helps and hinders the situation, new coping strategies, and the effect of the preceding steps on participants. This assessment was tested with eight ICU providers in an 11-bed community ICU. RESULTS During three one-hour sessions, participants described their moral distress that was caused by the use of ongoing life-support for a patient who the team believed did not prefer this course of care, but whose family was requesting it. Participants experienced frustration and discouragement and coping strategies included speaking to colleagues and exercising. They felt that they were unable to take meaningful action to resolve this conflict. Values that were in conflict in the situation included beneficence and patient autonomy. Based on ranking of helping and hindering factors, the team proposed new strategies including improving consistency of care plans and educating patients' family members and ICU personnel about advance care planning and end-of-life care. After completing this assessment, participants reported less stress and a greater ability to take meaningful action, including some of the proposed new strategies. CONCLUSIONS We found this new approach to address moral distress in ICU personnel to be feasible and a useful tool for facilitating plans for reducing moral distress.
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Affiliation(s)
- Peter M. Dodek
- grid.17091.3e0000 0001 2288 9830Centre for Health Evaluation and Outcomes Sciences (CHÉOS) and Division of Critical Care Medicine, St. Paul’s Hospital and The University of British Columbia, 588-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Kim Jameson
- grid.417243.70000 0004 0384 4428Vancouver Coastal Health Authority, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Centre for Applied Ethics, The University of British Columbia, Vancouver, BC Canada
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When is enough, enough? Exploring ethical and team considerations in paediatric cardiac care dilemmas. Curr Opin Cardiol 2022; 37:109-114. [PMID: 34698666 DOI: 10.1097/hco.0000000000000926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Therapies for paediatric congenital and acquired heart disease continue to evolve and the appropriateness of pursuing life sustaining interventions at margins of standard therapy is ethically challenging. RECENT FINDINGS With ongoing emphasis on shared decision making, recent literature explored physician and parental perspectives on communication with families and offering interventions for complex congenital heart disease and advanced heart failure. The inclusion of parental values and views in this process is now widely accepted. Identified outstanding challenges include difficulty with prognostication from the outset, adjusting long-term goals of care to changes in clinical parameters, need for consistency in communication including regular review meetings with family or surrogate decision-makers. Bioethics consultation and multidisciplinary team reviews may be helpful supports. Palliative care involvement in this population improves quality of life and alleviates parental distress but this collaboration is not optimized. SUMMARY Decision to offer, forgo, or discontinue life-sustaining therapies for children with heart disease has nuanced and context-specific considerations, and must integrate burdens of interventions with patient and family values. Thus, decision making remains complex and demands thoughtful review of not only risks and benefits, but views and values, clearly communicated to team and family.
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Caram CDS, Rezende LC, Fonseca MP, Almeida NG, Rezende LS, Nascimento J, Barreto BI. STRATEGIES FOR COPING WITH MORAL DISTRESS ADOPTED BY NURSES IN TERTIARY CARE: A SCOPING REVIEW. TEXTO & CONTEXTO ENFERMAGEM 2022. [DOI: 10.1590/1980-265x-tce-2021-0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
ABSTRACT Objective: to map the scientific evidence on strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care. Method: this is a Scoping Review based on the PRISMA-ScR recommendations. The searches were performed in September 2020 in the MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane and Biblioteca Virtual en Saúde databases. The eligibility criterion was to include studies that discussed strategies for coping with moral distress adopted by nurses in tertiary care, finding 2,041 studies, which were organized and screened in the Endnote software. The data were organized in Excel spreadsheets and analysis of the results was performed using the ATLAS.ti software. Results: the final selected sample consisted of 23 studies, which were grouped in two axes: strategies and recommendations. Four articles were included in the “strategies” axis, which reported actions taken to face moral distress, detailing the intervention and their results. The others, included in the “recommendations” axis, are articles whose focus was the experience of moral distress, suggesting important aspects to face it. Conclusion: recognition of moral distress by nurses and the opportunity for collective discussion and exchange of experiences are ways of collectively facing the situations. In addition, the institution's active participation in carrying out interventions was recommended. However, gaps were noticed in the production of studies that actually go deeper into intervention actions to cope with moral distress.
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Giannetta N, Sergi R, Villa G, Pennestrì F, Sala R, Mordacci R, Manara DF. Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study. Healthcare (Basel) 2021; 9:healthcare9121673. [PMID: 34946401 PMCID: PMC8701919 DOI: 10.3390/healthcare9121673] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 12/25/2022] Open
Abstract
Moral distress is a concern for all healthcare professionals working in all care settings. Based on our knowledge, no studies explore the differences in levels of moral distress in hospital and community settings. This study aims to examine the level of moral distress among healthcare professional working in community or hospital settings and compare it by demographic and workplace characteristics. This is a cross-sectional study. All the professionals working in the hospitals or community settings involved received personal e-mail invitations to participate in the study. The Moral Distress Thermometer was used to measure moral distress among healthcare professionals. Before data collection, ethical approval was obtained from each setting where the participants were enrolled. The sample of this study is made up of 397 healthcare professionals: 53.65% of the sample works in hospital setting while 46.35% of the sample works in community setting. Moral distress was present in all professional groups. Findings have shown that nurses experienced level of moral distress higher than other healthcare professionals (mean: 4.91). There was a significant differences between moral distress among different professional categories (H(6) = 14.407; p < 0.05). The ETA Coefficient test showed significant variation between healthcare professionals working in community and in hospital settings. Specifically, healthcare professionals who work in hospital experienced a higher level of moral distress than those who work in community settings (means 4.92 vs. means 3.80). The results of this study confirm that it is imperative to develop educational programs to reduce moral distress even in those settings where the level perceived is low, in order to mitigate the moral residue and the crescendo effect.
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Affiliation(s)
- Noemi Giannetta
- Faculty of Philosophy, Vita-Salute San Raffaele University, 20132 Milan, Italy; (N.G.); (R.S.); (F.P.); (R.S.); (R.M.)
| | - Rebecca Sergi
- Faculty of Philosophy, Vita-Salute San Raffaele University, 20132 Milan, Italy; (N.G.); (R.S.); (F.P.); (R.S.); (R.M.)
| | - Giulia Villa
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, 20132 Milan, Italy;
- Correspondence: ; Tel.: +39-022-643-2522
| | - Federico Pennestrì
- Faculty of Philosophy, Vita-Salute San Raffaele University, 20132 Milan, Italy; (N.G.); (R.S.); (F.P.); (R.S.); (R.M.)
| | - Roberta Sala
- Faculty of Philosophy, Vita-Salute San Raffaele University, 20132 Milan, Italy; (N.G.); (R.S.); (F.P.); (R.S.); (R.M.)
| | - Roberto Mordacci
- Faculty of Philosophy, Vita-Salute San Raffaele University, 20132 Milan, Italy; (N.G.); (R.S.); (F.P.); (R.S.); (R.M.)
| | - Duilio Fiorenzo Manara
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, 20132 Milan, Italy;
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Jansen TL, Hem MH, Danbolt LJ, Hanssen I. Coping with moral distress on acute psychiatric wards: A qualitative study. Nurs Ethics 2021; 29:171-180. [PMID: 34486442 PMCID: PMC8866740 DOI: 10.1177/09697330211010246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Nurses working within acute psychiatric settings often face multifaceted
moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services.
Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health
hospitals. Results: Various coping strategies were used: mentally sorting through their ethical
dilemmas or bringing them to the leadership, not ‘bringing problems home’
after work or loyally doing as told and trying to make oneself immune.
Colleagues and work climate were important for choice of coping
strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and
their private life. Not facing their moral distress seemed to come at a high
price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come
to terms with distressing events and identify and address the moral issues
they face. As moral distress to a great extent is an organisational problem
experienced at a personal level, it is important that a work climate is
developed that is open for ethical discussions and nourishes adaptive coping
strategies and moral resilience.
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Affiliation(s)
- Trine-Lise Jansen
- Lovisenberg diakonale høgskole (Lovisenberg Diaconal University College), Norway.,MF Norwegian School of Theology, Religion and Society, Norway
| | | | | | - Ingrid Hanssen
- 155319Lovisenberg diakonale høgskole (Lovisenberg Diaconal University College), Norway
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Abstract
Summary: Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.
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Bernuzzi C, Setti I, Maffoni M, Sommovigo V. From moral distress to burnout through work-family conflict: the protective role of resilience and positive refocusing. ETHICS & BEHAVIOR 2021. [DOI: 10.1080/10508422.2021.1955682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chiara Bernuzzi
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
| | - Ilaria Setti
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
| | - Marina Maffoni
- Psychology Unit of Montescano Institute, Istituti Clinici Scientifici Maugeri IRCCS
| | - Valentina Sommovigo
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
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Nursing Education: Students' Narratives of Moral Distress in Clinical Practice. NURSING REPORTS 2021; 11:291-300. [PMID: 34968206 PMCID: PMC8608063 DOI: 10.3390/nursrep11020028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Research indicates that newly graduated nurses are often unprepared for meeting challenging situations in clinical practice. This phenomenon is referred to as a "reality shock". This gap in preparedness may lead to moral distress. The aim of this article is to provide knowledge of moral distress in clinical nursing practice. METHODS Bachelor and further education nursing students were invited to write a story about challenging situations from their own clinical practice, resulting in 36 stories. Analysis was based on hermeneutical reading inspired by a narrative method; therefore, six stories were selected to represent the findings. RESULTS A finding across the stories is that the students knew the right thing to do but ended up doing nothing. Four themes were related to moral distress: (a) undermining of professional judgement, (b) disagreement concerning treatment and care, (c) undignified care by supervisors, and (d) colliding values and priorities of care. CONCLUSION Nursing education should emphasize to a greater extent ethical competency and training for the challenging situations students will encounter in clinical practice.
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Ventovaara P, Sandeberg MA, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics 2021; 28:1061-1072. [PMID: 33706607 PMCID: PMC8408826 DOI: 10.1177/0969733021994169] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ethical climate and moral distress have been shown to affect nurses' ethical behaviour. Despite the many ethical issues in paediatric oncology nursing, research is still lacking in the field. RESEARCH AIM To investigate paediatric oncology nurses' perceptions of ethical climate and moral distress. RESEARCH DESIGN In this cross-sectional study, data were collected using Finnish translations of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Data analysis includes descriptive statistics and non-parametric analyses. RESPONDENTS AND RESEARCH CONTEXT Ninety-three nurses, working at paediatric oncology centres in Finland, completed the survey. ETHICAL CONSIDERATIONS According to Finnish legislation, no ethical review was needed for this type of questionnaire study. Formal research approvals were obtained from all five hospitals. Return of the questionnaire was interpreted as consent to participate. RESULTS Ethical climate was perceived as positive. Although morally distressing situations were assessed as highly disturbing, in general they occurred quite rarely. The situations that did appear often reflected performing procedures on school-aged children who resist such treatment, inadequate staffing and lack of time. Perceptions of ethical climate and frequencies of morally distressing situations were inversely correlated. DISCUSSION Although the results echo the recurrent testimonies of busy work shifts, nurses could most often practise nursing the way they perceived as right. One possible explanation could be the competent and supportive co-workers, as peer support has been described as helpful in mitigating moral distress. CONCLUSION Nurturing good collegial relationships and developing manageable workloads could reduce moral distress among nurses.
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Affiliation(s)
| | | | | | - Pernilla Pergert
- 27106Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
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Luca CE, Cavicchioli A, Bianchi M. Nurses Who Assume the Role of Advocate for Older Hospitalized Patients: A Qualitative Study. SAGE Open Nurs 2021; 7:23779608211030651. [PMID: 34377782 PMCID: PMC8323413 DOI: 10.1177/23779608211030651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/12/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patient advocacy, acting on behalf of patients' unmet needs, is fundamental to nursing, and the perception of the need for advocacy motivated this study. Nurses experience moral discomfort, which results from a divergent view regarding medical or caregivers' decisions about patients' clinical proceedings, in which patients' involvement in making those decisions is either doubtful or absent. OBJECTIVES The aim of this study is to assess the need for advocacy and explore the perspectives of nurses engaged in the care of older patients. METHODS The methodological orientation is that of a qualitative design, by using a purposive and criterion sampling. The sample was of 14 nurses of a ward of general medicine. Focus group as collecting data tool was used, followed by a thematic analysis. RESULTS Nurses demonstrated a high level of moral sensitivity to ethical problems in clinical practice and on occasions, the courage to bring the problem to the physicians or patients' family's attention, or help patients develop self-determination. However, it is difficult to advocate because of insufficient communication between professionals, insufficient knowledge of ethics, and the emotional burden it places on nurses which results in emotional resignation in the face of interprofessional teams' lack of consideration of nurses' opinions. CONCLUSION This research highlighted nurses' need for advocacy to promote patients' rights, wishes, and values. It is essential for nurses to be aware of their level of moral sensitivity and develop a strategy to regain courage to engage in advocacy. Therefore, ethics education and interprofessional ethical leadership is desired, which inspires healthcare professionals' work and allows the foundations of an ethical decisionmaking process to be laid through patients and their families' active involvement.
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Affiliation(s)
- Corina Elena Luca
- Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano,
Lugano, Switzerland
| | - Andrea Cavicchioli
- Department of Business Economics, Health and Social Care, University of Applied Sciences and
Arts of Southern Switzerland, University of Applied Sciences and Arts of Southern
Switzerland, Manno, Switzerland
| | - Monica Bianchi
- Department of Business Economics, Health and Social Care, University of Applied Sciences and
Arts of Southern Switzerland, University of Applied Sciences and Arts of Southern
Switzerland, Manno, Switzerland
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