Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center

Moral resilience and intention to leave: Mediating effect of moral distress

AIMS

This study aims to examine the mediating effect of moral distress on the relationship between moral resilience and the intention to leave.

BACKGROUND

Moral distress is a phenomenon that negatively impacts healthcare workers, healthcare institutions, and recipients. To eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience is important in protecting against the negative effects of moral distress, such as burnout and turnover intention. In this direction, it is necessary to increase the moral resilience of nurses to reduce negative situations such as turnover intention in nurses.

METHODS

It is a descriptive-predictive study. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals, and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 220 clinical nurses were recruited.

ETHICAL CONSIDERATIONS

Approval was obtained from the university's non-interventional ethics committee, and informed consent was obtained from the participants.

RESULTS

The study found a total moral distress score of 6.39 ± 0.3.12 and moral resilience score of 2.69 ± 0.48. A moderate and weak negative correlation was found between moral distress and moral resilience. Moral distress has a moderating effect on the intention to leave nursing (β = -0.158, p = .010) and the intention to leave the current position (β = -0.174, p = .000). Individual's moral resilience directly affects the intention to leave. The presence of moral distress eliminates the direct effect of moral resilience and affects the intention to leave together with moral resilience.

CONCLUSIONS

Moral resilience leads to decreased intention to leave, and moral distress mediates this situation. An increase in moral distress decreases moral resilience and increases intention to leave. It can be assumed that if moral distress is not controlled, increasing moral resilience will not affect the intention to leave the job.

"The Patient Is Being Pressured!" Coercion Versus Relational Autonomy

Relational autonomy is a concept that describes the interdependent nature of decision making by individuals. Relational autonomy is distinct from the traditional concept of autonomy, which asserts the need for each individual to make choices based on their own values and without influence by others. We present a case in which a patient made decisions that appeared contrary to his own desires. The case raises questions about the line between appropriate and coercive family influence. We also explore the moral distress generated by the attempt to reconcile his expressed desires and the decisions he made. We propose that examining the case with a relational autonomy lens may have helped clinical staff understand his decision and thus mitigate moral distress.

Measuring moral distress in health professionals using the MMD-HP-SPA scale

BACKGROUND

Moral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes.

METHODS

A regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice.

RESULTS

The mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9).

CONCLUSIONS

Female, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

Moral Distress and Intention to Leave During COVID: A Cross-sectional Study on the Current Nursing Workforce to Guide Nurse Leaders for the Future

OBJECTIVE

The aim of this study was to investigate how the experience of caring for COVID-19 patients, nurses' moral distress, and the current practice environment impact nurses' intention to leave.

BACKGROUND

Caring for COVID-19 patients has been associated with an increase in nurses' moral distress and an increase in nurses' turnover. To date, research has focused on nurses' moral distress, the practice environment, and intentions to leave during the pandemic's peak. The current workplace climate, including those who stayed in their positions, has not been adequately assessed.

METHODS

This cross-sectional correlational study was conducted in a Magnet® hospital.

RESULTS

Moral distress related to team/system (B = 0.64, t = 3.86, P < 0.001), nurses' participation in hospital affairs (B = -2.21, t = -3.52, P < 0.001), and staffing (B = -1.91, t = -5.48, P < 0.001) are strongest predictors for nurses' intention to leave postpandemic.

CONCLUSIONS

Nurses in practice still report experiencing COVID-related moral distress; however; issues related to resources and staffing have the most substantial impact on intention to leave among the current nursing workforce.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Associação do Sofrimento Moral e Síndrome de Burnout em enfermeiros de hospital universitário

Resumo Objetivo: analisar a associação entre sofrimento moral e síndrome de Burnout em enfermeiros de hospital universitário. Método: estudo descritivo-analítico, realizado com 269 enfermeiros atuantes em um hospital universitário localizado no Rio Grande do Sul, Brasil. A coleta de dados ocorreu de maneira presencial no ano de 2019 por coletadores previamente capacitados. Aplicaram-se questionário sociodemográfico e laboral, Escala Brasileira de Distresse Moral em Enfermeiros e o Inventário Maslach de Burnout. Empregou-se análise estatística descritiva e analítica. Resultados: identificou-se associação entre intensidade e frequência de sofrimento moral e suas dimensões com a síndrome de Burnout e suas dimensões. Enfermeiros em baixa realização profissional e alta exaustão emocional apresentaram prevalências mais elevadas para sofrimento moral. Conclusão: evidenciou-se a associação entre sofrimento moral e síndrome de Burnout bem como entre suas dimensões. Os resultados sinalizam a necessidade de investigar intervenções urgentes para amenizar as situações e as manifestações do sofrimento moral e a síndrome de Burnout, elaborando estratégias para a saúde dos trabalhadores.

Asociación del Sufrimiento Moral y Síndrome de Burnout en enfermeros de un hospital universitario

Resumen Objetivo: analizar la asociación entre sufrimiento moral y síndrome de Burnout en enfermeros de un hospital universitario. Método: estudio descriptivo y analítico, realizado en 269 enfermeros que actuaban en un hospital universitario localizado en el estado de Rio Grande del Sur, en Brasil. La recogida de datos se realizó de manera presencial en el año de 2019 por colectores previamente capacitados. Se aplicaron el cuestionario sociodemográfico y laboral, la Escala Brasileña de Estrés Moral en Enfermeros y el Inventario Maslach de Burnout. Se empleó el análisis estadístico descriptivo y analítico. Resultados: se identificó asociación entre intensidad y frecuencia de sufrimiento moral y sus dimensiones con el síndrome de Burnout y sus dimensiones. Los enfermeros que tuvieron baja realización profesional y alta extenuación emocional, presentaron prevalencias más elevadas para el sufrimiento moral. Conclusión: se evidenció asociación entre sufrimiento moral y síndrome de Burnout así como entre sus dimensiones. Los resultados señalan la necesidad urgente de investigar intervenciones para amenizar las situaciones y las manifestaciones del sufrimiento moral y el síndrome de Burnout, elaborando estrategias para la salud de los trabajadores.

Effect of Structural Moral Case Deliberation on Burnout Symptoms, Moral Distress, and Team Climate in ICU Professionals: A Parallel Cluster Randomized Trial

OBJECTIVES

Moral case deliberation (MCD) is a team-based and facilitator-led, structured moral dialogue about ethical difficulties encountered in practice. This study assessed whether offering structural MCD in ICUs reduces burnout symptoms and moral distress and strengthens the team climate among ICU professionals.

DESIGN

This is a parallel cluster randomized trial.

SETTING

Six ICUs in two hospitals located in Nijmegen, between January 2020 and September 2021.

SUBJECTS

Four hundred thirty-five ICU professionals.

INTERVENTIONS

Three of the ICUs organized structural MCD. In three other units, there was no structural MCD or other structural discussions of moral problems.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes investigated were the three burnout symptoms-emotional exhaustion, depersonalization, and a low sense of personal accomplishment-among ICU professionals measured using the Maslach Burnout Inventory on a 0-6 scale. Secondary outcomes were moral distress (Moral Distress Scale) on a 0-336 scale and team climate (Safety Attitude Questionnaire) on a 0-4 scale. Organizational culture was an explorative outcome (culture of care barometer) and was measured on a 0-4 scale. Outcomes were measured at baseline and in 6-, 12-, and 21-month follow-ups. Intention-to-treat analyses were conducted using linear mixed models for longitudinal nested data. Structural MCD did not affect emotional exhaustion or depersonalization, or the team climate. It reduced professionals' personal accomplishment (-0.15; p < 0.05) but also reduced moral distress (-5.48; p < 0.01). Perceptions of organizational support (0.15; p < 0.01), leadership (0.19; p < 0.001), and participation opportunities (0.13; p < 0.05) improved.

CONCLUSIONS

Although structural MCD did not mitigate emotional exhaustion or depersonalization, and reduced personal accomplishment in ICU professionals, it did reduce moral distress. Moreover, it did not improve team climate, but improved the organizational culture.

Prevalence and Risk Factors for Moral Distress in Pediatric Oncology Health Care Professionals

PURPOSE

Moral distress (MoD) is prevalent among health care professionals (HCPs) in oncology and is associated with burnout. The objectives of this study were to quantify MoD among pediatric oncology healthcare professionals (HCPs) at a Canadian quaternary care hospital, identify root causes, and evaluate change over time.

METHODS

Eligible pediatric oncology HCPs were identified, and consenting participants completed the Measure of Moral Distress-Healthcare Professionals (MMD-HP) and MoD Thermometer (MDT) at baseline, followed by biweekly MDTs over 12 weeks.

RESULTS

A total of 139 HCPs participated. The mean MMD-HP score was 123 ± 57.0, range 9-288. Demographic risk factors identified for elevated MMD-HP scores were female sex (female 127.1 and male 83.6, P = .01) and nursing role (nurse 136.3 and most responsible physician 85.3, P = .02). Higher MMD-HP scores were found in HCPs who were currently considering resigning because of MoD compared with those who were not (169.9 v 115.4, P < .001). Situations involving administration of treatment to children with poor prognosis cancers that was perceived to be overly aggressive were ranked as the greatest environmental contributor to MoD. Baseline and mean MDT scores over time strongly correlated with MMD-HP scores (P < .0001 and P = .0003, respectively), with mean MDT scores showing no significant fluctuation over the 12-week period.

CONCLUSION

MoD was common among pediatric oncology HCPs. Risk factors for elevated levels of MoD included both demographic and environmental factors. Implementation of systems to improve team communication and decision making, especially in the care of patients with poor prognosis cancers, may affect HCP MoD.

Kidney Clinicians' Perceptions of Challenges and Aspirations to Improve End-Of-Life Care Provision

Introduction

End-of-life care is an essential part of integrated kidney care. However, renal clinicians' experiences of care provision and perceptions of end-of-life care needs are limited. This study explored renal clinicians' experiences of providing end-of-life care and developed recommendations to improve experiences.

Methods

An exploratory qualitative study using semistructured focus groups and 1 interview was undertaken at 5 kidney services in Victoria, Australia. The transcripts were analyzed thematically.

Results

Between February and December 2017, 54 renal clinicians (21 doctors and 33 nurses) participated in the study. Clinicians reported multiple challenges of end-of-life care experiences resulting in compromised treatment planning and decision making and highlighted priorities to guide better care experiences. Challenges of providing end-of-life care were underpinned by mismatches in illness and treatment expectations, limited engagement in advance care planning, medical complexity, and differences between clinicians and patients in what constituted quality of life. These challenges were associated with compromised end-of-life care planning, which resulted in care experiences that were rushed with a prolonged treatment focus, risking limited preparation for death and moral distress. Clinicians aspired for positive end-of-life care experiences, including patient control and consensus in decision making, and a coordinated and collaborative approach across healthcare providers.

Conclusions

Renal clinicians highlighted multiple factors and circumstances which resulted in experiences of compromised end-of-life care for patients with kidney disease. To improve care experiences, clinician-directed priorities included more training and support to facilitate systematic and earlier discussions about illness expectations and end-of-life care planning and greater communication and collaboration across healthcare providers is required.

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

BACKGROUND

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

METHODS

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

RESEARCH DESIGN

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

LGBTQ+ Identity and Ophthalmologist Burnout

PURPOSE

To evaluate lesbian, gay, bisexual, transgender, questioning, and other sexual/gender minority (LGBTQ+) orientation as a burnout risk factor among an international ophthalmologist cohort.

METHODS

An anonymous, cross-sectional electronic survey was distributed via an Internet platform to characterize the relationship among demographic factors, including LGBTQ+ orientation, and burnout as measured by the Copenhagen Burnout Inventory (CBI). Univariable data analysis (linear) by sexual orientation was performed and variables with an association with a P value of <0.15 in univariable analysis were included in the multiple linear regression modeling.

RESULTS

A total of 403 ophthalmologists participated in the survey. The majority self-identified as "White" (69.2%), were from North America (72.0% United States, 18.6% Canada) and were evenly distributed between age of 30 and 65 years. Overall, 13.2% of participants identified as LGBTQ+ and 98.2% as cisgender. Approximately 12% had witnessed or experienced LGBTQ+-related workplace discrimination or harassment. The personal and work-related burnout scores and confidence limits of persons identified as LGBTQ+ were higher and nonoverlapping compared with those reported as non-LGBTQ+. Multivariable analysis identified significant risk factors for higher personal and work-related burnout scores: LGBTQ+ (11.8 and 11.1, P = .0005 and .0023), female gender (5.36 and 4.83, P = .0153 and .0434), older age (19.1 and 19.2, P = .0173 and .0273). and caretaker stress (6.42 and 5.97, P = .0085 and .0239).

CONCLUSIONS

LGBTQ+ orientation is a burnout risk factor among ophthalmologists, and LGBTQ+ workplace discrimination may be a contributing factor. Support from ophthalmology organizations to address LGBTQ+-, gender-, and age-related workplace discrimination may decrease burnout. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

The Association of Professional Burnout and Turnover Intentions Among Intensive Care Units Physicians: A Cross-Sectional Study

Intensive Care Units (ICU) workers work in highly stressful conditions that make them prone to professional burnout, which can lead to high turnover rates. This study explores professional burnout levels among ICU workers in Kuwait general governmental hospitals (GGHs), their turnover intentions, and the correlation factors. A cross-sectional self-administered survey study was conducted. Professional burnout level was measured using the Copenhagen Burnout Inventory (CBI), while turnover intention was measured using the Turnover Intention Scale (TIS-6). Data were analyzed using STATA software, and descriptive, correlative, and comparative analyses were performed. Eighty-nine ICU physicians filled out the questionnaire. Most of the participants were males, married, non-Kuwaiti nationals, with 10 to 20 years of experience, and the mean age of respondents was 39.2. The total professional burnout score was high was 54.7 (17.6). There were high total average scores for the personal and work-related domains. Participants who were younger than 35 years of age and graduated before 5 to 10 years had higher levels of professional burnout compared to other groups. More than half of the sample expressed their intention to leave their current job as an ICU physician. However, no association was found between turnover intentions and levels of burnout. High levels of professional burnout of turnover intentions were seen among ICU physicians in Kuwait. Policies should be adopted to reduce and mitigate professional burnout among ICU physicians and increase their retention. Future research should further investigate professional burnout among ICU staff, the associated factors, and its relation to their turnover intention.

Association between Moral Distress and Burnout Syndrome in university-hospital nurses

OBJECTIVE

to analyze the association between moral distress and Burnout Syndrome among nurses in a university hospital.

METHOD

descriptive, analytical study conducted with 269 nurses working in a university hospital located in Rio Grande do Sul, Brazil. Data were collected in person in 2019 by previously trained collectors. A sociodemographic and employment questionnaire, the Brazilian Scale of Moral Distress in Nurses and the Maslach Burnout Inventory were applied. Descriptive and analytical statistical analysis was used.

RESULTS

an association was identified between moral distress intensity and frequency and its dimensions with Burnout Syndrome and its dimensions. Nurses with low professional achievement and high emotional exhaustion showed a higher prevalence of moral distress.

CONCLUSION

an association between moral distress and Burnout Syndrome, as well as between their dimensions, was evidenced. The results suggest the need to investigate urgent interventions to mitigate the situations and manifestations of moral distress and Burnout Syndrome by developing strategies for workers' health.

Critical Care Providers' Moral Distress: Frequency, Burden, and Potential Resources

BACKGROUND

Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD).

AIM

To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources.

METHODS

A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses).

RESULTS

Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden.

CONCLUSIONS

MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.