Psycometric characteristics of the Moral Distress Scale in Brazilian nursing professionals

An evaluation of moral distress among healthcare workers during COVID-19 pandemic in Palestine

BACKGROUND

Moral distress among healthcare workers (HCWs) is considered a serious issue in all aspects of healthcare divisions, which needs an urgent intervention.

AIMS

The study aims at evaluating moral distress among HCWs which will help the healthcare management and decision-makers in hospitals and health centers to act in a comprehensiveness and effective way by reinforcing moral thinking and behavior in selected coronavirus (COVID-19) quarantine centers across Palestine.

METHODS

Ninety-four HCWs were selected by convenience sampling method. Data were collected using revised Corley's Standard Moral Distress (MD) Scale and analyzed using SPSS software version 23.

RESULTS

The mean score of MD for HCWs was low (1.24 ± 0.71). The mean score of MD severity was moderate (1.4 ± 0.93). The severity and frequency of MD in HCWs had a significant reverse relationship with years of experience, number of children of worker, and duration of work with COVID-19 patients.

CONCLUSION

It is important to create a professional psychological support system for HCWs to decrease MD when facing moral issues.

Development and Validation of a Moral Distress Scale for Nursing Students

Background and Purpose

This study aimed to develop and validate a scale to measure the frequency and the intensity of the moral distress experienced by nursing students.

Method

Methodological study in which a guideline with eight steps: (a) to determine what to measure, (b) to produce items, (c) format to measure, (d) review by experts, (e) validation of items, (f) sample, (g) assessment (h) scale length was used to develop and validate a scale. The sample was composed of 499 undergraduate nursing students from three Brazilian universities.

Results

Six constructs were identified in the factor analysis. The instrument and dimensions presented satisfactory internal consistency, with Cronbach's alpha coefficients equal to .97 and between .60 and .97, respectively.

Conclusion

The developed scale is able to analyze the intensity and the frequency of Moral Distress in nursing students, in a valid and reliable way.

Intensity and frequency of moral distress in Brazilian nurses

OBJECTIVE

To evaluate the frequency and intensity of moral distress in Brazilian nurses.

METHOD

Cross-sectional study performed with nurses from 27 Brazilian states through application of the Brazilian Moral Distress Scale in Nurses (Portuguese acronym: EDME-Br) and descriptive statistical analysis.

RESULTS

Participation of 1,226 Brazilian nurses in the study. The intensity and frequency of overall moral distress were rated as moderate level, with averages of 3.08 (± 1.45) and 2.94 (± 1.37), respectively. Specifically, the highest intensity and frequency was related to the factors Acknowledgement, power and professional identity and Work teams, while the lowest was related to the factor Defense of values and rights.

CONCLUSION

Moral distress occurs in precarious work environments, with little expressiveness of the nurses' role. One highlights the importance of the problem in terms of its amplitude and multicausality, reaching professionals acting in different work contexts.

Moral Distress and its Influential Factors in the Nurses of the Nursing Homes in Khorasan Provinces in 2019: A Descriptive-Correlational Study

Background:

Nurses in nursing homes are constantly faced with various moral decisions in terms of elderly care, which in turn causes moral distress. This study aimed to evaluate the moral distress status and its influential factors in the nursing homes in Khorasan provinces, Iran.

Materials and Methods:

This descriptive-correlational study was conducted on 227 nurses engaged in the nursing homes of Khorasan provinces in 2019. The subjects were selected via census sampling. Data were collected using demographic, occupational, and care center characteristics questionnaire and a moral distress questionnaire. Data analysis was performed in SPSS version 16 using the Mann–Whitney U and Kruskal–Wallis test.

Results:

The mean (SD) score of moral distress was 28.68 (19.19), and 93.83% of the subjects reported low levels of moral distress. Significant correlations were observed between moral distress and age, work experience, workplace, nurse–physician relations, motivation of the nurses, care facilities, and medical equipment. Furthermore, the highest mean (SD) score of moral distress belonged to the items regarding the lack of work experience 12.19 (3.12).

Conclusions:

According to the results, moral distress in the nurses of the studied nursing home was relatively low. Despite the favorable outcome of the study, the age discrimination of nurses by nursing homes should not be overlooked.

Analytical study of care quality and moral distress in clinical situations and patient care

Objective

Nursing profession conventionally meets a high standard of ethical behavior and action. One of the ethical challenges in nursing profession is moral distress. Nurses frequently expose to this phenomenon which leads to different consequences such as being bored by delivering patient care that decline care quality and make it challenging to achieve health purposes. This study was conducted to investigate the association between the aspects of moral distress and care quality.

Methods

In this descriptive–analytical study, 545 nurses of intensive and cardiac care units and dialysis and psychiatric wards were recruited by census sampling. Three questionnaires, Sociodemographics, Moral Distress Scale, and Quality Patient Care Scale, were distributed among the participants and collected within 9 months. Data analysis was conducted by descriptive statistics, analysis of variance, and the least significant difference in SPSS 13.

Results

Investigating moral distress domains (ignoring patient, decision-making power, and professional competence) and care quality domains (psychosocial, physical, and communicational) demonstrated that in being exposed to moral distress, ignoring patient had no effect on psychosocial domain (P=0.056), but decision-making and professional competence of moral distress had positive effect on psychosocial, physical (bodily), and communication domains of care quality.

Conclusions

Because moral distress domains are effective on patient care quality, it is recommended to enhance the knowledge of nurses, especially beginners, about moral distress, increase their strength alongside standardizing nursing services in decision-making domains, improve the professional competence, and pay attention to patients.

Validation of the Brazilian Moral Distress Scale in Nurses

Background and Purpose

To determine the psychometric properties of the Brazilian Moral Distress Scale in Nurses (MDSN-BR).

Design

In this methodological, cross-sectional study, the criterion, content, and construct validation stages were presented.

Method

A 57-item questionnaire was applied to 1,227 brazilian nurses through an online form. The exploratory factor analyses revealed significant conceptual relations among its items in six constructs, expressing the consistency of the scale.

Results

The validated version of the instrument consists of six constructs and 49 items—Cronbach's alpha .980 (instrument) and of constructs: (a) (.942) Acknowledgment, power, and professional identity; (b) (.961) Safe and qualified care; (c) (.924) Defense of values and rights; (d) (.944) Work conditions; (e) (.933) Ethical infractions; (f) (.914) Work teams.

Conclusion

The results provide evidence supporting the reliability and trustworthiness of the scale in the selected population.

Ethical conflicts and their characteristics among critical care nurses

INTRODUCTION

Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored.

AIM

The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire-Critical Care Version and, second, to analyse Portuguese critical care nurses' level of exposure to ethical conflict and its characteristics.

METHODS

A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016.

ETHICAL CONSIDERATIONS

The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental.

FINDINGS

The Portuguese version of the Ethical Conflict Nursing Questionnaire-Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources.

Generating situations of Moral Distress in Primary Care Nurses

OBJECTIVE

To analyze the situations generating Moral Distress in Primary Care nurses from different regions of Brazil.

METHOD

Qualitative research, with 13 nurses of the Brazilian Primary Health Care, through a semi-structured interview and submitted to the Discursive Textual Analysis, with the resources of the software ATLAS.ti 7.0.

RESULTS

They are presented in four categories, relating the Moral Distress to the professional; health services; users and conflicts in professional practice.

FINAL CONSIDERATIONS

By assuming ethical and political values as guides to their action, nurses give greater visibility to the moral content of many problems and weaknesses that could be seen only by the bias of working conditions.

Moral distress in undergraduate nursing students

BACKGROUND

Moral distress is considered to be the negative feelings that arise when one knows the morally correct response to a situation but cannot act because of institutional or hierarchal constraints.

OBJECTIVES

To analyze moral distress and its relation with sociodemographic and academic variables in undergraduate students from different universities in Brazil.

METHOD

Quantitative study with a cross-sectional design. Data were collected through the Moral Distress Scale for Nursing Students, with 499 nursing students from three universities in the extreme south of Brazil answering the scale. The data were analyzed in the statistical software SPSS version 22.0, through descriptive statistical analysis, association tests (t-test and analysis of variance), and linear regression models.

ETHICAL CONSIDERATIONS

Approval for the study was obtained from the Research Ethics Committee at Universidade Federal do Rio Grande.

FINDINGS

The mean intensity of moral distress in the constructs ranged from 1.60 to 2.55. As to the occurrence of situations leading to moral distress in the constructs, the frequencies ranged from 1.21 to 2.43. The intensity level of moral distress showed higher averages in the more advanced grades of the undergraduate nursing course, when compared to the early grades of this course (between 5 and 10 grade, average = 2.60-3.14, p = 0.000).

CONCLUSION

The demographic and academic characteristics of the undergraduate nursing students who referred higher levels of moral distress were being enrolled in the final course semesters, were at a federal university, and had no prior degree as an auxiliary nurse/nursing technician.

Moral Distress Assessment in the Nursing Team of a Hematology-Oncology Sector

ABSTRACT Objective: To identify the frequency and intensity of Moral Distress, and to analyze the associations between Moral Distress and sociodemographic and labor characteristics of the nursing team of a Hematology-Oncology. Method: A cross-sectional study was carried out with 46 nursing professionals from a Hematology-Oncology sector of a hospital institution in Rio Grande do Sul State, Brazil, through the application of the Moral Distress Scale - Brazilian version. In the data analysis, descriptive statistics and nonparametric association tests were used. Results: Mortal Distress intensity of 3.27 (SD= 1.79) and frequency of 1.72 (SD= 1.02) were found in this team. The Moral Distress of greater intensity and frequency were related to the denial of the role of Nursing as a patient's advocate and the disrespect to the patient's autonomy, respectively. Conclusion: It is suggested a greater space for discussion among professionals, multiprofessional team and managers, so that adequate conditions of action and communication are provided.

The moral deliberation process of college nursing professors in view of moral distress

STUDY AIM

To discover college nursing professors' deliberation and coping strategies in view of moral distress.

DESIGN

Qualitative study with a descriptive and exploratory design.

SETTING AND PARTICIPANTS

The participants were 12 college nursing professors who taught at three public universities in Brazil.

METHODS

The adapted Delphi method was applied. The data were collected in three phases with concomitant data collection and analysis.

FINDINGS

Moral distress in teaching can lead to the development of strategies that promote moral deliberation through individual and collective actions, including the defense of principles and dialogue. At the same time, it can produce compensatory mechanisms of preservation and no personal involvement, as well as perceptions of impotence and discouragement, which do not lead to the construction of alternatives of resistance and deliberation. There is no polarization between professor who deliberate or not, as these can be mobile positions taken at certain times and in certain situations, influenced by bonds and support conquered in the group, and not just by leadership and personal characteristics.

CONCLUSION

Dialogue is a fundamental tool for the practice of moral deliberation in the conflicts and challenges of teaching work.

DESCRIPTORS

Faculty, Nursing; Moral Development; Choice Behavior; Interpersonal Relations.

A Second-Order Confirmatory Factor Analysis of the Moral Distress Scale-Revised for Nurses

Background:

Moral distress is a growing problem for healthcare professionals that may lead to dissatisfaction, resignation, or occupational burnout if left unattended, and nurses experience different levels of this phenomenon.

Objectives:

This study aims to investigate the factor structure of the Persian version of the Moral Distress Scale–Revised in intensive care and general nurses.

Research design:

This methodological research was conducted with 771 nurses from eight hospitals in the Mazandaran Province of Iran in 2017. Participants completed the Moral Distress Scale–Revised, data collected, and factor structure assessed using the construct, convergent, and divergent validity methods. The reliability of the scale was assessed using internal consistency (Cronbach’s alpha, Theta, and McDonald’s omega coefficients) and construct reliability.

Ethical considerations:

This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences.

Findings:

The exploratory factor analysis ( N = 380) showed that the Moral Distress Scale–Revised has five factors: lack of professional competence at work, ignoring ethical issues and patient conditions, futile care, carrying out the physician’s orders without question and unsafe care, and providing care under personal and organizational pressures, which explained 56.62% of the overall variance. The confirmatory factor analysis ( N = 391) supported the five-factor solution and the second-order latent factor model. The first-order model did not show a favorable convergent and divergent validity. Ultimately, the Moral Distress Scale–Revised was found to have a favorable internal consistency and construct reliability.

Discussion and conclusion:

The Moral Distress Scale–Revised was found to be a multidimensional construct. The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. Since the convergent and divergent validity of the scale were not confirmed in this study, further assessment is necessary in future studies.

CONSTRUÇÃO DA ESCALA BRASILEIRA DE DISTRESSE MORAL EM ENFERMEIROS - UM ESTUDO METODOLÓGICO

RESUMO Objetivo: desenvolver um instrumento denominado Escala Brasileira de Distresse Moral em Enfermeiros, para medição da intensidade e frequência do distresse moral. Método: pesquisa metodológica descrita em três etapas: 1) definição do marco teórico (background); 2) concepção do instrumento; e 3) composição do instrumento. A etapa 2 integrou a revisão da literatura e survey para identificar elementos/situações desencadeadoras de distresse moral. A amostra consistiu de 771 enfermeiros, dos 27 estados do Brasil, atuantes em diferentes serviços. Resultados: foram analisadas situações de distresse moral apreendidas pelo survey, em cinco rodadas envolvendo grupo de pesquisadores, produzindo uma matriz analítica com nove categorias e 72 subcategorias, que subsidiaram a formulação das questões iniciais, aprimoradas e cotejadas com os achados da literatura (validação de critério). Outras três rodadas foram realizadas para composição do instrumento, com 57 questões e dupla escala Likert, em sucessivas revisões do conteúdo, linguagem, formato e layout, incluindo a avaliação por experts/juízes e análise dos resultados do pré-teste (validação de face/conteúdo). Conclusão: explorar condições específicas do contexto brasileiro do trabalho de enfermeiros e a validação do instrumento produzido permitirá compreender o tema do sofrimento moral no cenário da enfermagem brasileira. Construir instrumentos próprios capazes de aferir expressões de distresse moral pode referendar problemas éticos já descritos com instrumentos adaptados.

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

Background:

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

Objective:

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

Research design:

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

Ethical considerations:

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

Findings:

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

Discussion and conclusion:

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

Moral distress of nursing undergraduates: Myth or reality?

INTRODUCTION

During their education process, nursing undergraduates experience ethical conflicts and dilemmas that can lead to moral distress. Moral distress can deprive the undergraduates of their working potential and may cause physical and mental health problems.

OBJECTIVE

We investigated the experiences of the undergraduates in order to identify the existence of moral distress caused by ethical conflict and dilemmas experienced during their nursing education. Ethical considerations: This study was designed according to the principles of research with human beings and was approved by the Human Research Ethics Committee.

METHOD

A qualitative multiple-case study. Two federal higher education institutions were surveyed, from which 58 undergraduates in nursing participated in the study. The undergraduates were undergoing their professional training. The data were collected through focus groups and were submitted to thematic content analysis, with the resources of the ATLAS TI 7.0 software.

RESULTS

Moral distress in undergraduates is a reality and was identified in three axes of analysis: (1) moral distress is experienced by undergraduates in the reality of healthcare services, (2) the teacher as a source of moral distress, and (3) moral distress as a positive experience.

CONCLUSION

The undergraduates in nursing manifest moral distress in different stages of their education, particularly during their professional training. The academic community should reflect and seek solutions for the reality of moral distress in undergraduates.

CONCEPTUAL FRAMEWORK FOR THE STUDY OF MORAL DISTRESS IN NURSES

ABSTRACT The objective of this reflective study was to propose conceptual elements for the analysis of moral distress as a process that articulates various concepts of moral experience. The moral distress is explored as a phenomenon manifested in different scenarios and dimensions of labor - care, management and education. Although a relative consensus exists on the concept and comparable empirical results in several countries, there are limited studies that explore theoretical gaps, critical points and possibilities to expand the analytical potential. In the search for consistent and updated theoretical supports for the changing needs of the field, the state of the art was surveyedn and a conceptual framework was designed to address moral distress as a process that articulates various concepts or moments of moral experience, such as uncertainty, moral sensitivity and moral deliberation. The proposed matrix articulates the development process of moral competencies or the construction of the ethical subject, present in pedagogical and philosophical discourses of interest to the profession.

ELEMENTS AND STRATEGIES FOR ETHICAL DECISION-MAKING IN NURSING

ABSTRACT This study aimed to identify the elements and strategies that facilitate the ethical decision-making of nurses faced with ethical problems, from publications on the theme. An integrative literature review was carried out. Data collection was performed between the months of April and May 2014, in the databases: SciELO, CINAHL, LILACS and MEDLINE. Original, theoretical and case study articles, with a health team that included nurses, published in Portuguese, English and Spanish were included. A total of 19 studies were selected, the analysis of which resulted in three categories: external factors of ethical decision-making in nursing, individual factors of ethical decision-making in nursing and facilitating strategies of ethical decision-making in nursing. It was concluded that nurses need to use strategies that develop sensitivity, ability and ethical competence, in order to make prudent ethical decisions, contributing to the quality of health care.