Moral distress in nursing personnel

Health advocacy and moral distress among nurses in organ transplant units

BACKGROUND

Health advocacy is crucial for both patients and healthcare professionals. However, nurses who recognize the importance of health advocacy may experience heightened moral distress, particularly in complex donation and transplantation cases where patient autonomy, respect, and advocacy are paramount.

AIM

To identify the factors contributing to moral distress among nurses working in solid organ transplant units at a university hospital in São Paulo, with a focus on health advocacy.

RESEARCH DESIGN

This descriptive, cross-sectional study employs both quantitative and qualitative methods. For this, the quantitative phase of the study was conducted utilizing the Moral Distress Scale, while the qualitative phase was executed through focus group discussions.

PARTICIPANTS AND RESEARCH CONTEXT

The quantitative phase involved 15 nurses using the Moral Distress Scale. The qualitative phase consisted of a focus group with 5 nurse managers/coordinators from the transplant units. Quantitative data were analyzed using R® software, while qualitative data were analyzed using Bardin's Content Analysis.

ETHICAL CONSIDERATIONS

The study was approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing, University of São Paulo. Participation was voluntary and confidentiality was ensured.

RESULTS

A significant correlation was found between moral distress and the factors of "disregard for patient autonomy" (p = .0100) and "therapeutic obstinacy" (p = .0492).

CONCLUSION

The primary determinants associated with moral distress in the context of health advocacy were identified as "disregard for patient autonomy" and "therapeutic obstinacy."

An educational program of reducing moral distress (PRMD) in nurses; designing and evaluating

BACKGROUND

Moral distress is common phenomenon that has negative consequences on nurses, patients, and healthcare systems. This study aims to design and evaluate an educational program to reduce moral distress in nurses.

METHODS

This multiphase mixed-method study was done in three stage on February 2021 in Shiraz/Iran. In pre-implementation stage, a content analysis study was conducted on 12 participants were interviewed using purposive sampling and then the program was designed according to qualitative data, panel of expertise and literature review according the seven steps of Ewles and Sminett's model and implemented in one group on 40 nurses using a quasi-experimental design. In Post-Implementation stage, effectiveness of program was evaluated through quantitative and qualitative methods. Quantitative data were gathered by Hamric's 21-question moral distress questionnaire analyzed via SPSS v.25 and analysis of variance repeated measures test. Also, a content analysis study was conducted on 6 PRMD participants using purposive sampling. In Program evaluation stage, convergence of quantitative and qualitative data and the effects of the program were examined. Trustworthiness of qualitative data was accomplished by Lincoln and Guba criteria.

RESULTS

First quantitative study revealed the causes of moral distress consisted of deficiency in professional competency, unsuitable organizational culture, personal factors, environmental and organizational factors, management factors, insufficiencies in proficient and efficient communication and nurses' observation of moral dilemma. Results of quantitative stage showed that there was a significant difference (p < 0.05) between the mean score of moral distress before, after, 1 and 2 months after the intervention. The participants in secondary qualitative stage, reported increasing their moral knowledge and skills, improving ethical climate, and moral empowerment.

CONCLUSION

The use of different educational tools and teaching methods and the participation of managers in designing strategies had a very effective role in the effectiveness of this educational program.

Analysis of moral courage and related factors among undergraduate nursing students: a scoping review

OBJECTIVE

to analyze scientific evidence on moral courage and related factors among nursing undergraduate students.

METHOD

the protocol of this scoping review was registered on Open Science Framework. A search was performed in five databases, according to the method provided by Joanna Briggs Institute Reviewers, the mnemonic strategy Population, Concept and Context, and a specific checklist.

RESULTS

a total of 2,812 results were identified, but only nine studies were eligible and presented three thematic approaches: Moral courage from the perspective of nursing students; Moral courage and related factors; and The teaching of moral courage in the training of nursing students. The factors related to moral courage include moral distress, moral sensitivity, age, and having a previous degree in the health field.

FINAL CONSIDERATIONS

few studies were found with a low evidence level. Most were performed in developed countries, indicating some gaps that need to be addressed in the future.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Privacy awareness among healthcare professionals in intensive care unit: A multicenter, cross-sectional study

This multicenter, cross-sectional study aimed to determine and examine the privacy awareness and patient rights education of healthcare professionals working in intensive care units (ICUs). The primary purpose of this study was to determine the privacy awareness of healthcare professionals working in the ICU. In addition, the secondary aim was to examine the relationship between patient rights education and awareness scores, as well as to question the need for privacy awareness education. The study population consisted of ICU physicians, nurses, and allied health personnel working in university hospitals, training and research hospitals, state hospitals, and private hospitals in Turkey. The data were collected through a questionnaire prepared by the researchers, including a question set about sociodemographics, a question about patient rights education, and the privacy awareness scale (PAS) scores using online Google Forms. In the results of the study conducted among 569 participants, the mean total PAS score was 38.31 ± 2.54. The PAS score was significantly different according to the occupation. The PAS scores of the nurses were higher than physicians and allied health personnel. The PAS scores differed according to whether the participants had received patient rights education. This study found that nurses were the group with the highest PAS scores among healthcare professionals. In addition, the PAS scores of nurses working in private and training and research hospitals were higher than those of other hospital employees. On the other hand, the lowest scores belonged to university hospitals and receiving patient rights education increased the PAS score of the nurses. This study showed that all enrolled healthcare professionals required in-service training to gain privacy awareness.

Alarm fatigue and moral distress in ICU nurses in COVID-19 pandemic

INTRODUCTION

Most ICU nurses feel overwhelmed by the variety of alarms at the same time. Therefore, nurses experience very stressful situations in relation to many responsibilities and care demands. This stressful condition has recently been exacerbated by COVID-19 and potentially endangers patient safety. The aim of this study was to investigate the alarm fatigue and moral distress of ICU nurses in COVID-19 crisis.

METHOD

This is a descriptive-analytical cross-sectional study (April-May 2021). Sampling was done by convenience among ICU nurses affiliated to Isfahan University of Medical Sciences, Iran. Data were collected using Nurses' alarm fatigue and the moral distress scale (MDS). Data were analyzed using ANOVA, independent t-test and multivariate logistic regression.

RESULT

The results showed that the mean score of alarm fatigue was moderate)19.08 ± 6.26 (and moral distress was low (33.80 ± 11.60). The results showed that there was a significant relationship between alarm fatigue and related training courses)P = .012(.So that, alarm fatigue in nurses who were trained in working with ventilators and alarm settings was significantly less than other nurses. Also, a significant relationship was found between moral distress and marital status(P = .001) and Shift type(P = .01). On the other hand, the risk of alarm fatigue was higher in participants who have a PhD. The results showed that no significant correlation was found between alarm fatigue and moral distress (r = 0.111, P = 0.195).

CONCLUSION

It is suggested that practical training courses on alarm management be included in the curriculum and the ICU nurses should have practical training before starting work in the ICU and on an annual basis. In order to protect nurses and ensure quality care of patients, nurse managers should reduce the number of rotating shifts of ICU nurses.

STRATEGIES FOR COPING WITH MORAL DISTRESS ADOPTED BY NURSES IN TERTIARY CARE: A SCOPING REVIEW

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.

Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature

The concept of moral distress comes from nursing ethics, and was initially defined as ‘…when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation.

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.

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.

Sofrimento moral e satisfação profissional: qual a sua relação no trabalho do enfermeiro?

RESUMO Objetivo Verificar relações entre sofrimento moral e satisfação profissional no trabalho de enfermeiros no contexto hospitalar. Método Estudo transversal, realizado em um hospital universitário com enfermeiros por meio da aplicação de questionário sociodemográfico, Índice de Satisfação Profissional e Moral Distress Scale – Versão Brasileira. Para a análise, empregaram-se a estatística descritiva e a correlação de Spearman. Resultados Participaram do estudo 141 enfermeiros. A “autonomia” foi o componente de maior satisfação profissional, aparecendo fragilizada nas questões de maior intensidade de sofrimento moral. Seguiram-se à autonomia a “interação” e “remuneração” como componentes de satisfação; e “falta de competência na equipe” e “condições de trabalho insuficientes” como de maior intensidade e frequência de sofrimento moral, respectivamente. Conclusão As aproximações entre esses dois constructos denotaram relações inversas entre eles, principalmente ao passo que a autonomia, componente de maior satisfação, também se configura num desencadeador de sofrimento moral quando insuficientemente exercida. Considera-se a necessidade de fortalecimento dos ambientes de trabalho da enfermagem para uma atuação ética e satisfatória.

Ethical dilemmas in nursing: An integrative review

AIMS

To identify themes and gaps in the literature to stimulate researchers to develop strategies to guide decision-making among clinical nurses faced with ethical dilemmas.

BACKGROUND

The concept of ethical dilemmas has been well explored in nursing because of the frequency of ethical dilemmas in practice and the toll these dilemmas can take on nurses. Although ethical dilemmas are prevalent in nursing practice, frequently leading to moral distress, there is little guidance in the literature to help nurses resolve them.

DESIGN

This study is an integrative review of published research from 2000 to 2017.

METHODS

The keywords ethics, ethical dilemmas and nurs* were searched in CINAHL, PubMed, OVID and SCOPUS. Exclusion criteria were sources not available in English, not in acute care, and without an available abstract. Seventy-two studies were screened; 35 were retained. Garrard's matrix was utilised to analyse and synthesise the studies.

RESULTS

Ethical dilemmas arose from end-of-life issues, conflict with physicians or families, patient privacy concerns and organisational constraints. Differences were found in study location, and yet international research confirms that ethical dilemmas are universally prevalent and must be addressed globally to protect patients and nurses.

CONCLUSIONS

This review offers an analysis of the available evidence regarding ethical dilemmas in acute care, identifying themes, limitations and gaps in the literature. The gaps in quantitative intervention work, US paucity of research, and lack of comparisons across practice settings/nursing roles must be addressed. Further exploration is warranted in the relationship between ethical dilemmas and moral distress, the significance patient physical appearance plays on nurse determination of futility, and strategies for pain management and honesty.

RELEVANCE TO NURSING PRACTICE

Understanding and addressing gaps in research is essential to develop strategies to help nurses resolve ethical dilemmas and to avoid moral distress and burnout.

A scale-development study: Exploration of intensive-care nurses' attitudes towards futile treatments

The study was conducted to determine the validity and reliability of the tool used to assess nurses' attitudes towards futility, and to explore intensive-care nurses' attitudes towards futility. Principal components analysis revealed that 18item scale was made up of four subdimensions that assess Identifying(beliefs), Decision-Making, Ethical Principles and Law, and Dilemma and Responsibilities related to futile treatments. The internal consistency of the scale was in the acceptable range, with a total Cronbach's alpha value of 0.72. Overall the results of study suggest that scale can be used as a valid and reliable assessment tool to assess nurses' attitudes towards futility.

Health advocacy by nurses in the Family Health Strategy: barriers and facilitators

OBJECTIVE

Identify the barriers and facilitators of health advocacy to users delivered by nurses from the Family Health Strategy.

METHOD

Qualitative study carried out with nurses from the Family Health Strategy of a city in the south of Brazil. Study participants were 15 nurses, who were interviewed. The content of the interviews was recorded, transcribed and analyzed in the light of the discursive text analysis.

RESULTS

Two categories emerged, one about the lack of organization at the workplace, bureaucracy and limitations to professional work in health environments, and another about the facilitating aspects to exercise advocacy both individually and collectively.

CONCLUSION

When nurses, provided with technical, scientific and relational knowledge, are empowered to make decisions, they are not only supported by other professionals at work but also develop actions of health advocacy to users, thus qualifying the care delivered.

ADVOCACIA DO PACIENTE NA ENFERMAGEM: BARREIRAS, FACILITADORES E POSSÍVEIS IMPLICAÇÕES

RESUMO Objetivo: realizar uma reflexão acerca das barreiras, facilitadores e possíveis implicações do exercício da advocacia do paciente pelos enfermeiros. Resultados: essa reflexão resulta de uma leitura minuciosa da literatura internacional acerca da advocacia do paciente, acrescida de estudos nacionais e internacionais acerca do sofrimento moral e suas relações com o exercício da advocacia. Conclusão: as barreiras diante do exercício da advocacia do paciente são notórias, pautando-se na própria estrutura organizacional das instituições de saúde e nas relações de poder entre equipes médica e de enfermagem, desafiando e desencorajando os enfermeiros a agirem de acordo com seus conhecimentos e consciências, implicando, muitas vezes, em situações reconhecidas como de sofrimento moral.

Moral distress in Turkish intensive care nurses

BACKGROUND

Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress suffered by nurses nor a study conducted on the issue.

AIM/OBJECTIVE

The study aims to (a) validate the Turkish version of the Moral Distress Scale-Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses' moral distress level.

METHOD

The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale-Revised. Ethical considerations: The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.

RESULTS

In parallel with the original scale, Turkish version of Moral Distress Scale-Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.

CONCLUSION

Turkish version of Moral Distress Scale-Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care.

Sofrimento moral em enfermeiros dos departamentos de fiscalização do Brasil

Resumo Objetivo Identificar a frequência e a intensidade das causas de sofrimento moral vivenciado por enfermeiros nos departamentos de fiscalização do Brasil. Métodos Estudo transversal realizado com 28 profissionais de competência gerencial e 113 profissionais de competência fiscalizatória. A amostra foi intencional e não probabilística. Os dados foram obtidos por meio de questionário e submetidos à análise descritiva e bivariada. Resultados Os participantes revelaram causas do sofrimento moral em dois momentos: Primeiro associado ao processo de fiscalização lento por parte das instituições fiscalizadas e Corens; e insuficiência de recursos humanos. Segundo associado aos problemas éticos; condições de trabalho; e qualidade da assistência de enfermagem. Conclusão Refletir sobre as causas do sofrimento moral neste cenário é reconhecer a necessidade de algumas mudanças que devem acontecer na base que sustenta os preceitos éticos e condutas morais da profissão, para assim fortalecer a categoria.

COMO ENFERMEIROS VÊM EXERCENDO A ADVOCACIA DO PACIENTE NO CONTEXTO HOSPITALAR? - UMA PERSPECTIVA FOUCAULTIANA

Objetivou-se conhecer como os enfermeiros vêm exercendo a advocacia do paciente no contexto hospitalar. Realizou-se uma pesquisa qualitativa, do tipo exploratório-descritiva, em um hospital universitário do Sul do Brasil. Foram respondentes da pesquisa 16 enfermeiros, selecionados por meio de amostragem não probabilística, do tipo bola de neve. Para a coleta de dados, foram realizadas entrevistas semiestruturadas, gravadas e transcritas, analisadas mediante análise textual discursiva e referencial teórico foucaultiano. Como resultados, emergiram duas categorias: a coragem de verdade: o exercício da advocacia mediado pelo diálogo franco; estratégias de resistência para o exercício da advocacia do paciente. Conclui-se que a estabilidade profissional e o apoio da instituição contribuem para que os enfermeiros se sintam encorajados a exercer a advocacia, mesmo diante de situações de difícil enfrentamento, utilizando-se da parrésia e de estratégias de resistência para garantir a defesa efetiva dos interesses dos pacientes.

Nursing beliefs and actions in exercising patient advocacy in a hospital context

AbstractOBJECTIVEAnalyzing beliefs and actions of nurses in exercising patient advocacy in a hospital context.METHODA quantitative cross-sectional exploratory and descriptive study, conducted with 153 nurses from two hospitals in southern Brazil, one public and one philanthropic, by applying Protective Nursing Advocacy Scale - Brazilian version. Data were analyzed using descriptive statistics and analysis of variance.RESULTSNurses believe they are advocating for patients in their workplaces, and agree that they should advocate, especially when vulnerable patients need their protection. Personal values and professional skills have been identified as major sources of support for the practice of advocacy.CONCLUSIONNurses do not disagree nor agree that advocating for patients in their working environments can bring them negative consequences. It is necessary to recognize how the characteristics of public and private institutions have helped or not helped in exercising patient advocacy by nurses.

Moral sensitivity and moral distress in Iranian critical care nurses

BACKGROUND

Moral sensitivity is the foremost prerequisite to ethical performance; a review of literature shows that nurses are sometimes not sensitive enough for a variety of reasons. Moral distress is a frequent phenomenon in nursing, which may result in paradoxes in care, dealing with patients and rendering high-quality care. This may, in turn, hinder the meeting of care objectives, thus affecting social healthcare standards.

RESEARCH OBJECTIVE

The present research was conducted to determine the relationship between moral sensitivity and moral distress of nurses in intensive care units.

RESEARCH DESIGN

This study is a descriptive-correlation research. Lutzen's moral sensitivity questionnaire and Corley Moral Distress Questionnaire were used to gather data. Participants and research context: A total of 153 qualified nurses working in the hospitals affiliated to Shahid Beheshti University of Medical Sciences were selected for this study. Subjects were selected by census method. Ethical considerations: After explaining the objectives of the study, all the participants completed and signed the written consent form. To conduct the study, permission was obtained from the selected hospitals.

FINDINGS

Nurses' average moral sensitivity grade was 68.6 ± 7.8, which shows a moderate level of moral sensitivity. On the other hand, nurses also experienced a moderate level of moral distress (44.8 ± 16.6). Moreover, there was no meaningful statistical relationship between moral sensitivity and moral distress (p = 0.26).

DISCUSSION

Although the nurses' moral sensitivity and moral distress were expected to be high in the intensive care units, it was moderate. This finding is consistent with the results of some studies and contradicts with others.

CONCLUSION

As moral sensitivity is a crucial factor in care, it is suggested that necessary training be provided to develop moral sensitivity in nurses in education and practical environments. Furthermore, removing factors that contribute to moral distress may help decrease it in nurses.

Constructing a theoretical model of moral distress

Moral distress has been characterised as one of the main ethical problems affecting nurses in all health systems, and has been depicted as a threat to nurses' integrity and to the quality of patient care. In recent years, several studies tried to investigate moral distress, its causes and consequences for health professionals, clients and organisations. However, such studies are considered controversial and vulnerable, mainly because they lack a solid philosophical and empirical basis. The present article aimed at elaborating a theoretical model for moral distress, considering the process of moral deliberation, spaces of power and resistance and patient advocacy, and sought to carry out a reflection that culminated with the creation of a broader concept of moral distress.

Confronting moral distress in Nursing: recognizing nurses as moral agents

The concept of moral distress has brought forth a substantively different way of understanding some of the difficulties confronted by nurses in their practice. This concept highlights that nurses' distress can be an indication of nurses' conscientious moral engagement with their professional practice that has confronted practices or an environment that impedes them from acting according to their own ethical standards. Moral distress can be an indicator of problems in nurses' practice environments. This concept is described and related to moral agency in nursing practice. Selected research on moral distress is reviewed, followed by a discussion of recommendations for addressing this problem.