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Oelhafen S, Monteverde S, Trachsel M. Overestimating prevalence? Rethinking boundaries and confounders of moral distress. J Health Psychol 2024:13591053241253233. [PMID: 38780231 DOI: 10.1177/13591053241253233] [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: 05/25/2024] Open
Abstract
Moral distress denotes a negative reaction to a morally challenging situation. It has been associated with adverse outcomes for healthcare professionals, patients and healthcare institutions. We argue that existing definitions, along with measures of moral distress, compromise the validity of empirical research. First, the definition and measurement of moral distress conflate moral events and psychological distress, even though they are distinct phenomena that should be assessed independently. Second, in many studies, there is a lack of clarity in distinguishing between moral and non-moral events. Finally, prior research on moral distress often overlooks the substantial body of evidence demonstrating the impact of diverse work-related factors, beyond moral events, on both distress and job retention. These challenges might undermine the effectiveness of interventions aimed at alleviating moral distress. We outline a comprehensive research agenda that encompasses conceptual clarifications, the refinement of data collection instruments, the design of studies and the application of appropriate statistical methods.
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Affiliation(s)
| | - Settimio Monteverde
- Bern University of Applied Sciences, Switzerland
- University of Zurich, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital Basel (USB), University Psychiatric Clinics (UPK) Basel, Geriatric University Hospital Felix Platter Basel, and University Children's Hospital Basel, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
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Beil-Hildebrand MB, Kundt Sari F, Kutschar P, Birkholz L. What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland. Leadersh Health Serv (Bradf Engl) 2024; ahead-of-print. [PMID: 38639984 DOI: 10.1108/lhs-09-2023-0075] [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: 04/20/2024]
Abstract
PURPOSE Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.
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Affiliation(s)
| | - Firuzan Kundt Sari
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Patrick Kutschar
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Lorri Birkholz
- School of Nursing, Chatham University, Pittsburgh, Pennsylvania, USA
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Thomas TA, Kumar S, Davis FD, Boedeker P, Thammasitboon S. Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals. AJOB Empir Bioeth 2024; 15:120-132. [PMID: 38165288 DOI: 10.1080/23294515.2023.2297922] [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: 01/03/2024]
Abstract
OBJECTIVE Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress. DESIGN Cross-sectional survey. SETTING Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States. PARTICIPANTS Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study. MAIN OUTCOME MEASURES Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM). RESULTS Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82). CONCLUSIONS We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.
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Affiliation(s)
- Tessy A Thomas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Health System, Danville, PA, USA
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Shelley Kumar
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - F Daniel Davis
- Center for Bioethics & Decision Sciences, Geisinger Health System, Danville, PA, USA
| | - Peter Boedeker
- Department of Education, Innovation and Technology, Baylor College of Medicine, Houston, TX, USA
| | - Satid Thammasitboon
- Center for Research, Innovation and Scholarship in Health Professions Education, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Kim DT, Shelton W, Applewhite MK. Clinician Moral Distress: Toward an Ethics of Agent-Regret. Hastings Cent Rep 2023; 53:40-53. [PMID: 38131494 DOI: 10.1002/hast.1544] [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: 12/23/2023]
Abstract
Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well-understood in terms of what Bernard Williams calls "agent-regret." We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience.
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Nzinga J, Oliwa J, Oluoch D, Jepkosgei J, Mbuthia D, Boga M, Musitia P, Ogola M, Muinga N, Muraya K, Hinga A, Kamuya D, Kelley M, Molyneux S. The hidden emotional labour behind ensuring the social value of research: Experiences of frontline health policy and systems researchers based in Kenya during COVID-19. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002116. [PMID: 37643165 PMCID: PMC10464993 DOI: 10.1371/journal.pgph.0002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/23/2023] [Indexed: 08/31/2023]
Abstract
Health policy and systems research (HPSR) is a multi-disciplinary, largely applied field of research aimed at understanding and strengthening the performance of health systems, often with an emphasis on power, policy and equity. The value of embedded and participatory HPSR specifically in facilitating the collection of rich data that is relevant to addressing real-world challenges is increasingly recognised. However, the potential contributions and challenges of HPSR in the context of shocks and crises are not well documented, with a particular gap in the literature being the experiences and coping strategies of the HPSR researchers who are embedded in health systems in resource constrained settings. In this paper, we draw on two sets of group discussions held among a group of approximately 15 HPSR researchers based in Nairobi, Kenya, who were conducting a range of embedded HPSR studies throughout the COVID-19 pandemic. The researchers, including many of the authors, were employed by the KEMRI-Wellcome Trust Research Programme (KWTRP), which is a long-standing multi-disciplinary partnership between the Kenya Medical Research Institute and the Wellcome Trust with a central goal of contributing to national and international health policy and practice. We share our findings in relation to three inter-related themes: 1) Ensuring the continued social value of our HPSR work in the face of changing priorities; 2) Responding to shifting ethical procedures and processes at institutional and national levels; and 3) Protecting our own and front-line colleagues' well-being, including clinical colleagues. Our experiences highlight that in navigating research work and responsibilities to colleagues, patients and participants through the pandemic, many embedded HPSR staff faced difficult emotional and ethical challenges, including heightened forms of moral distress, which may have been better prevented and supported. We draw on our findings and the wider literature to discuss considerations for funders and research leads with an eye to strengthening support for embedded HPSR staff, not only in crises such as the on-going COVID-19 pandemic, but also more generally.
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Affiliation(s)
- Jacinta Nzinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorothy Oluoch
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Joyline Jepkosgei
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Daniel Mbuthia
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mwanamvua Boga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peris Musitia
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Muthoni Ogola
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Naomi Muinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Alex Hinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorcas Kamuya
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Maureen Kelley
- Nuffield Department of Population Health, Wellcome Centre for Ethics & Humanities, University of Oxford, Oxford, United Kingdom
| | - Sassy Molyneux
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Rushton CH. Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice. Am J Crit Care 2023; 32:238-248. [PMID: 37391375 DOI: 10.4037/ajcc2023207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Ethical challenges are inherent in nursing practice. They affect patients, families, teams, organizations, and nurses themselves. These challenges arise when there are competing core values or commitments and diverse views on how to balance or reconcile them. When ethical conflict, confusion, or uncertainty cannot be resolved, moral suffering ensues. The consequences of moral suffering in its many forms undermine safe, high-quality patient care, erode teamwork, and undermine well-being and integrity. My experience as a nurse in the pediatric intensive care unit and later as a clinical nurse specialist in confronting these moral and ethical challenges has been the foundation of my program of research. Together we will explore the evolution of our understanding of moral suffering-its expressions, meanings, and consequences and attempts to measure it. Moral distress, the most described form of moral suffering, took hold within nursing and slowly within other disciplines. After 3 decades of research documenting the existence of moral distress, there were few solutions. It was at this juncture that my work pivoted toward exploring the concept of moral resilience as a means for transforming but not eliminating moral suffering. The evolution of the concept, its components, a scale to measure it, and research findings will be explored. Throughout this journey, the interplay of moral resilience and a culture of ethical practice were highlighted and examined. Moral resilience is continuing to evolve in its application and relevance. Many vital lessons have been learned that can inform future research and guide interventions to harness the inherent capabilities of clinicians to restore or preserve their integrity and to engage in large-scale system transformation.
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Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is the Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics, and a professor of nursing and pediatrics, Johns Hopkins University School of Nursing, Baltimore, Maryland
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Abstract
Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases ("Moral Distress Reflective Debriefs"). We discuss how the debriefing literature and other clinical ethics activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress.
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Sale ACG, Smith-Morris C. Moral Distress Under Structural Violence: Clinician Experience in Brazil Caring for Low-Income Families of Children with Severe Disabilities. Camb Q Healthc Ethics 2023; 32:1-13. [PMID: 36636810 DOI: 10.1017/s0963180122000779] [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: 01/14/2023]
Abstract
Rigorous attention has been paid to moral distress among healthcare professionals, largely in high-income settings. More obscure is the presence and impact of moral distress in contexts of chronic poverty and structural violence. Intercultural ethics research and dialogue can help reveal how the long-term presence of morally distressing conditions might influence the moral experience and agency of healthcare providers. This article discusses mixed-methods research at one nongovernmental social support agency and clinic in Rio de Janeiro, Brazil. Chronic levels of moral distress and perceptions of moral harm among clinicians in this setting were both violent, following Nancy Scheper-Hughes' use of that term, and a source of exceptional and innovative care. Rather than glossing over the moral variables of work in such desperate extremes, ethnography in these settings reveals novel skills and strategies for managing moral distress.
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Affiliation(s)
- Ana Carolina Gahyva Sale
- Department of Anthropology, Southern Methodist University, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, O'Donnell School of Public Health, Dallas, Texas75390-9096, USA
| | - Carolyn Smith-Morris
- Department of Anthropology, Southern Methodist University, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, O'Donnell School of Public Health, Dallas, Texas75390-9096, USA
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Jakobsen L, Olsen RM, Brinchmann BS, Devik SA. Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences. SAGE Open Nurs 2023; 9:23779608221150725. [PMID: 36654853 PMCID: PMC9841835 DOI: 10.1177/23779608221150725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/17/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses. Objective To investigate how digital ethical reflection can support ethics work among nurses working in long-term care. Methods A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA). Results During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager. Conclusions Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.
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Affiliation(s)
- Lena Jakobsen
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway,Lena Jakobsen, Faculty of Nursing and Health Sciences, Nord University, PO Box 1490, 8049 Bodø, Norway.
| | - Rose Mari Olsen
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
| | - Berit Støre Brinchmann
- Faculty of Nursing and Health Sciences, Nord University, Norway and Nordland Regional University, Bodø, Norway
| | - Siri Andreassen Devik
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
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Федотова Т. ПЕРЕЖИВАННЯ МОРАЛЬНОГО ДИСТРЕСУ ОСОБИСТОСТЮ: ТЕОРЕТИЧНЕ ОСМИСЛЕННЯ ПРОБЛЕМИ. PSYCHOLOGICAL PROSPECTS JOURNAL 2022. [DOI: 10.29038/2227-1376-2022-40-fed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Мета статті полягає у теоретичному аналізі проблеми морального дистресу в науковій літературі, з’ясуванні основних аспектів вивчення відповідної проблематики та встановленні особливостей прояву морального дистресу шляхом вторинного аналізу результатів емпіричних досліджень науковців.
Методи. У статті застосовано методи теоретичного вивчення наукової літератури (аналіз, синтез, узагальнення, систематизація підходів науковців) стосовно висвітлення проблеми переживання морального дистресу.
Результати. Проблеми морального дистресу в науковій літературі висвітлюється здебільшого шляхом її вивчення в ході реалізації професійної діяльності медичних працівників. Моральний дистрес розглядають як моральні страждання, які виникають в особистості в ситуації наявності знань про те, яким чином потрібно діяти, але неможливості діяти відповідно, через встановлені інституційних обмежень. Виокремлюють види морального дистресу: первинний (описують власне як моральний дистрес) та реактивний (розглядається як «моральний залишок»). Емпіричними маркерами морального дистресу є: почуття гніву, розчарування та провини, неможливість втілення морального судження в дію, невпевненість у собі, відсутність наполегливості, конформізм, уявне безсилля, відсутність критичності і розуміння ситуації тощо. Фізичними наслідками тривалого переживання морального дистресу для особистості можуть бути: безсоння, нудоту, мігрені, кишково-шлункові розлади, плаксивість та значне фізичне виснаження. В якості необхідної та/або достатньої умови переживання морального дистресу, на думку науковців, можуть виступати: моральне судження/необхідність вибору, інституційне/правове обмеження, психологічний ефект/вплив, моральний конфлікт, загроза моральної цілісності та автентичності, внутрішні обмеження та моральний клімат установи. У єдності з теорією морального дистресу розглядають теорію моральної розплати, стрижнем якої є аналіз переживання моральної розплати медсестрою: легкість, ситуативна прив’язка, вирішення та рефлексія.
Висновки. Здійснений теоретичний аналіз проблеми морального дистресу засвідчив складність та неоднозначність у визначені відповідного поняття, його показників та чинників. Теоретична розвідка означеної проблематики вказує на доцільність та важливість ґрунтованого вивчення морального дистресу з урахуванням вікового, статевого та професійного аспектів, а також актуальність та необхідність розробки програми психологічної підтримки осіб, які переживають моральний дистрес, комплексу заходів для збереження психічного здоров’я вразливих верств населення в умовах військових дій.
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Jansen TL, Danbolt LJ, Hanssen I, Hem MH. How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study. BMC Psychiatry 2022; 22:212. [PMID: 35321674 PMCID: PMC8944013 DOI: 10.1186/s12888-022-03832-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 02/23/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts. METHODS Qualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen. RESULTS While nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients' behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them. CONCLUSIONS Mental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat. Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.
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Affiliation(s)
- Trine-Lise Jansen
- Norway, MF Norwegian School of Theology, Religion and Society, Lovisenberg Diakonale Høgskole (Lovisenberg Diaconal University College), Oslo, Norway.
| | | | - Ingrid Hanssen
- Lovisenberg Diakonale Høgskole (Lovisenberg Diaconal University College), Oslo, Norway
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Selander K, Nikunlaakso R, Laitinen J. Association between work ability and work stressors: cross-sectional survey of elderly services and health and social care service employees. Arch Public Health 2022; 80:83. [PMID: 35292109 PMCID: PMC8922061 DOI: 10.1186/s13690-022-00841-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Work in the health and social care services (HSS) is very stressful and sickness absences are high. Nevertheless, little is known about their work stressors and work ability. The first aim of this study is to describe the prevalence of different work stressors and their accumulation among eldercare workers compared to general HSS workers. Second aim is to analyze associations between different work stressors and work ability and thus provide information on factors that are important in enhancing work ability. METHODS This cross-sectional survey examined HSS employees in Finland in 2020. The response rate was 67% (N = 22,502). Descriptive analyses were used to describe the control variables and the differences between the work stressors of general HSS and eldercare employees. After this, multinomial logistic regression analysis revealed the association between work stressors and work ability. RESULTS Eldercare employees experienced more often moral distress than HSS employees in general, and this further lowers their work ability. Single work stressors--Karasek's strain, Siegrist's ERI, organizational injustice and moral distress--increased the odds of low work ability (OR range 1.4-2.5) in comparison to no work stressors. However, the association with single stressors was roughly one third of that with the accumulation of all four work stressors (OR = 6.8). Thus, the accumulation of several stressors was most harmful for work ability. CONCLUSIONS This study provides novel information on the accumulation of work stressors in relation to work ability. The results suggest that in order to enhance work ability, HSS organizations should pay more attention to preventing several stressors from accumulating. Eldercare organizations in particular need to develop effective measures for lowering moral distress.
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13
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Begerow A, Gaidys U. [ "I am in conflict with myself every day"-Moral distress among geriatric nurses during the COVID-19 pandemic]. HEILBERUFESCIENCE 2022; 13:59-68. [PMID: 35127300 PMCID: PMC8801926 DOI: 10.1007/s16024-022-00366-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
Background Due to the COVID-19 pandemic-related changes and guidelines, nurses in the setting of inpatient geriatric care are exposed to specific burdens and may experience dilemmas with respect to their moral responsibility. Aim The aim of this study was to explicate the effects and perceptions regarding the development of moral distress of nurses in the setting of geriatric care during the SARS-CoV‑2 pandemic in Germany and to draw conclusions for the design of care in residential care settings. Methods Based on a subgroup analysis (n = 510) of the qualitative survey of the COVID-19 Nursing Study, perceptions of nurses working in residential care settings during the pandemic are presented and evaluated with respect to the development of moral distress. Results The results show five categories ("That we have no time to care properly", "Loneliness", "Conflicts with relatives and residents", "Constant fear for patient safety but also for one's own safety" and "Grief, stress and anger"), which represent differentiated criteria for the development of moral distress among nurses as well as its effects. Conclusion It can be concluded that structural and professional solutions must be developed that enable nurses to shape their own working environment and to undertake professional nursing decision-making competence.
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Affiliation(s)
- A. Begerow
- Department Pflege und Management, Hochschule für Angewandte Wissenschaften Hamburg, Alexanderstr. 1, 20099 Hamburg, Deutschland
| | - U. Gaidys
- Department Pflege und Management, Hochschule für Angewandte Wissenschaften Hamburg, Alexanderstr. 1, 20099 Hamburg, Deutschland
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14
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Abstract
Today, more than we are aware of in the history of health services in the United States, is the critical need to reclaim and apply the core values and principles that inspired physicians and nurses to respond to their original call become consolers and healers of the sick and those in distress, and to refocus our attention on the person of the healer. In clinical practice today, we are endowed with enormously effective interventions that were unimaginable only a few decades earlier. In light of the fund of knowledge, clinical competencies, and technological advancements that we bring to bear in our experience in caring for our patients, the learning curve is never flat, never complete, and never static. Newer, safer, and more effective interventions in the cure of illnesses, management to relieve stress, moderate fear of surgery, and to promote healing that often lead to early discharge and return to normal activities of daily living are readily available in clinical practice. Yet, there are looming threats that compromise the person of clinician, for example, dehumanization, consumerism, commodification, and fungeability of the human person. This article will describe the Trilogy of Health Care: Caring and Healing of the Clinician and its application to the care and healing of physicians and nurses as they accompany one another in caring for a world in need of healing and hope.
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Affiliation(s)
- Bro. Ignatius Perkins
- School of Nursing, Spalding University, Louisville, KY, USA,Brother Ignatius Perkins, OP, PhD, RN, FAAN, ANEF, FNYAM, FRSM, FNCBC, School of Nursing, Spalding University, 981 S. Third St, Louisville, KY 40203-2213, USA.
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15
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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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16
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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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17
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Morley G, Field R, Horsburgh CC, Burchill C. Interventions to mitigate moral distress: A systematic review of the literature. Int J Nurs Stud 2021; 121:103984. [PMID: 34214894 DOI: 10.1016/j.ijnurstu.2021.103984] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Moral distress is a pervasive phenomenon that can negatively impact healthcare professionals and has been well studied in nursing populations. Much of the evidence suggests that it is associated with intention to leave high acuity areas and the profession. Despite the increasing amounts of research to explore the causes and effects of moral distress, there is limited research on interventions that mitigate the negative effects of moral distress. OBJECTIVES The aims of this systematic review were to: (a) identify and examine interventions developed to address moral distress experienced by health care professionals (b) examine the quality of the research methods and (c) report on the efficacy of these interventions. DESIGN We conducted a systematic review of interventional studies developed to mitigate moral distress. DATA SOURCE Medline, Embase, PsycINFO, CINAHL and Cochrane were searched for relevant studies (July 2019- September 2019). Additional bioethics databases and reference lists were also hand-searched. REVIEW METHODS The first author reviewed all retrieved titles and abstracts with a low tolerance for borderline papers based on inclusion and exclusion criteria, and those papers were reviewed and discussed by all authors to determine inclusion. Quality appraisal was conducted on the included studies using narrative synthesis to compare the findings. Data were extracted and compared by all authors and then reviewed by the first author for consistency. RESULTS Sixteen papers were included for full text review and the following interventions identified: educational interventions of varying length and breadth; facilitated discussions ranging from 30 to 60 minutes; specialist consultation services; an intervention bundle; multidisciplinary rounds; self-reflection and narrative writing. Researchers reported statistically significant reductions in moral distress using pre and post surveys, including one mixed methods program evaluation (n=7). The qualitative program evaluation provided participant quotations to suggest their program was beneficial. There were no statistically significant findings in the other studies (n=8). All studies had limitations in design and methodology presenting significant threats to validity. CONCLUSION Designing rigorous research studies that measure the impact of interventions aimed at mitigating moral distress continues to be challenging. The primary reason being that moral distress is a subjective ethical phenomenon with a number of different causes and effects. This calls for interventions that are flexible and sensitive to individual's needs. To build an evidence-base, interventions should also be measurable and research methods need to be scientifically rigorous. To achieve rigor and innovation, researchers should clearly justify their methodological choices. Tweetable abstract: Interventions to mitigate moral distress: a systematic review of the literature. Educational interventions offer a promising direction but more research is needed.
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Affiliation(s)
- Georgina Morley
- Center for Bioethics and Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
| | - Rosemary Field
- Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic Marymount Hospital, 12300 McCracken Road, Garfield Heights, Cleveland, 44125, OH, USA.
| | - Cristie Cole Horsburgh
- Center for Bioethics, Clinical Transformation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
| | - Christian Burchill
- Office of Nursing Research and Innovation, Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
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18
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Haltaufderheide J, Gather J, Juckel G, Schildmann J, Vollmann J. Types of Ethical Problems and Expertise in Clinical Ethics Consultation in Psychiatry - Insights From a Qualitative Empirical Ethics Study. Front Psychiatry 2021; 12:558795. [PMID: 34113266 PMCID: PMC8185018 DOI: 10.3389/fpsyt.2021.558795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Ethics consultation has been advocated as a valuable tool in ethically challenging clinical situations in healthcare. It is paramount for the development and implementation of clinical ethics support services (CESS) in psychiatry that interventions can address the moral needs of mental health professionals adequately and communicate the nature of the services clearly. This study explores types of ethical problems and concepts of ethical expertise as core elements of CESS in mental healthcare with the aim of contributing to the further development of ethical support in psychiatry. Methods: We conducted 13 semi-structured interviews with mental health professionals and CESS members and triangulated them with four non-participant observations of ethical case consultations in psychiatry. Data were analyzed according to principles of grounded theory and are discussed from a normative perspective. Results: The analysis of the empirical data reveals a typology of three different ethical problems professionals want to refer to CESS: (1) Dyadic problems based on the relationship between patients and professionals, (2) triangular problems, where a third party is involved and affected as a side effect, and (3) problems on a systemic level. However, CESS members focus largely on types (1) and (2), while the third remains unrecognized or members do not feel responsible for these problems. Furthermore, they reflect a strong inner tension connected to their role as ethical experts which can be depicted as a dilemma. On the one hand, as ethically trained people, they reject the idea that their judgments have expert status. On the other hand, they feel that mental health professionals reach out for them to obtain guidance and that it is their responsibility to offer it. Conclusion: CESS members and professionals in mental healthcare have different ideas of the scope of responsibility of CESS. This contains the risk of misunderstandings and misconceptions and may affect the quality of consultations. It is necessary to adapt concepts of problem solving to practitioners' needs to overcome these problems. Secondly, CESS members struggle with their role as ethical experts. CESS members in psychiatry need to develop a stable professional identity. Theoretical clarification and practical training are needed.
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Affiliation(s)
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany.,Department of Psychiatry, Psychotherapy, and Preventive Medicine, LWL University Hospital, Ruhr University, Bochum, Germany
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy, and Preventive Medicine, LWL University Hospital, Ruhr University, Bochum, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
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[Moral distress in medical students and young professionals: research desiderata in the context of the COVID-19 pandemic]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1483-1490. [PMID: 33180160 PMCID: PMC7659897 DOI: 10.1007/s00103-020-03244-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
Hintergrund Die COVID-19-Pandemie stellt Menschen, die in der medizinischen Versorgung arbeiten, vor besondere Herausforderungen. Ein Teil der Medizinstudierenden und ärztlichen Berufseinsteigenden, die in dieser Zeit in Einrichtungen der Gesundheitsversorgung ihre Mitarbeit beginnen, wird mit außergewöhnlichen moralischen Herausforderungen konfrontiert. Einige verfügen noch nicht über ausreichend Bewältigungsmöglichkeiten, um adäquat mit diesen Herausforderungen umzugehen. Dies kann zu sogenanntem moralischen Stress (MoS; Englisch: „moral distress“, MoD) führen. Dauerhafte oder intensive Belastung durch MoS kann gravierende Folgen haben. Geeignete Unterstützungsangebote haben das Potenzial, den Umgang mit MoS zu verbessern. Ziel Der Beitrag hat das Ziel, einen Überblick über den Stand der Forschung zu MoS von Medizinstudierenden und ärztlichen Berufseinsteigenden zu geben, um Lehrende mit Aus- und Weiterbildungsverantwortung und Ärzt*innen in Leitungspositionen für die Problematik zu sensibilisieren. Hauptteil In diesem Beitrag werden das wissenschaftliche Konzept MoS, bekannte Auslöser sowie Präventions- und Interventionsmöglichkeiten vorgestellt. Dazu wird das Thema Bezug nehmend auf die Veränderungen in der Patientenversorgung im Kontext der COVID-19-Pandemie analysiert und es werden Forschungsdesiderate aufgezeigt. Fazit Der Beitrag verdeutlicht die Notwendigkeit eines deutschsprachigen, interdisziplinären Diskurses über MoS bei Medizinstudierenden und Berufseinsteigenden.
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20
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Abstract
AIM The aim of this national study was to explore student and faculty personal experiences of ethical dilemmas in nursing education and clinical practice. BACKGROUND Nurses encounter complex ethical dilemmas in practice that can lead to moral distress when they cannot "do the right thing" because of external constraints. METHOD A mixed-methods study via online survey was conducted on senior nursing student members and faculty advisors of the National Student Nurses Association. Over 1,600 students and 600 faculty answered a "two-minute survey" with the question: "Please describe an ethical dilemma you have experienced." RESULTS Descriptive statistics demonstrated a difference in student and faculty reports about the ethics content they received. The qualitative results from constant comparison of open-ended questions also supported differences in themes from student and faculty perspectives. CONCLUSION This study supports that students and faculty voice their concerns with different ethical dilemmas in their nursing education experiences.
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21
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Yucel SC, Ergin E, Orgun F, Gokçen M, Eser I. Validity and reliability study of the Moral Distress Questionnaire in Turkish for nurses. Rev Lat Am Enfermagem 2020; 28:e3319. [PMID: 32813786 PMCID: PMC7426139 DOI: 10.1590/1518-8345.2960.3319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/07/2020] [Indexed: 11/21/2022] Open
Abstract
Objective: to determine the validity and reliability of the Turkish language version of the Moral Distress Questionnaire for nurses. Method: methodological study whose sample consisted of 200 nurses working in the internal medicine and surgery clinics of a university hospital. Data was collected using the personal information form and the Moral Distress Questionnaire for nurses. Results: in the Main Components Analysis, the items were grouped under three factors. Findings regarding confirmatory factor analysis: chi-square goodness: 2.28, goodness of fit index: 0.88, comparative fit index: 0.88, non-normed fit index: 0.86, root mean square error of approximation: 0.07. The Cronbach’s alpha coefficient was found to be 0.79 as a result of the analysis conducted in order to test the internal consistency of the scale. It was seen that these three factors explained 44.92% of the total variance. Conclusion: in this present study, the Turkish version of the Moral Distress Questionnaire was found to be valid and reliable for the Turkish society. It is recommended that the Moral Distress Questionnaire for nurses should be used in future studies to be conducted with nurses in order to investigate of issues of ethical dilemma.
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Affiliation(s)
| | - Eda Ergin
- Faculty of Health Sciences, İzmir Bakircay University, İzmir, Turkey
| | - Fatma Orgun
- Nursing School, Ege University, İzmir, Turkey
| | | | - Ismet Eser
- Nursing School, Ege University, İzmir, Turkey
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22
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Newham R. Morality, normativity and measuring moral distress. Nurs Philos 2020; 22:e12319. [PMID: 32790120 DOI: 10.1111/nup.12319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 11/30/2022]
Abstract
It is known that people have been getting distressed for a long-time and healthcare workers, like the military, seem to fit criteria for being at particular risk. Fairly recently a term of art, moral distress, has been added to types of distress at work, though not restricted to work, they can suffer. There are recognized scales that measure psychological distress such as the General Health Questionnaire and the Kessler scales but moral distress it is claimed is different warranting its own scale. This seems to be because of both the intensity and nature of moral problems encountered at work that is so powerful and so destructive of moral agency and integrity. This paper will focus on how, if at all, moral distress is different by examining the idea of moral normativity. Moral normativity is understood as roughly the sort of thing that all rational persons would endorse regardless of his interests, having an "automatic reason giving force" and is likely to also require an overriding force. Specifically, it will examine how this force of moral claims seems to be needed for moral distress to be so destructive of healthcare professional's moral agency and integrity. This is related to the idea of warrantedness of the reaction of distress. Even if morality had such a strong normativity, one can still ask is distress the correct or warranted reaction? It seems plausible that if distress is a correct response for it to be both moral and warranted it needs a strong account of moral normativity. The idea of a distinct form of distress as moral distress may be true in theory but is too contested both ontologically and epistemologically for a useful practice of measurement at present.
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Affiliation(s)
- Roger Newham
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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23
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Dorman JD, Raffin Bouchal S. Moral distress and moral uncertainty in medical assistance in dying: A simultaneous evolutionary concept analysis. Nurs Forum 2020; 55:320-330. [PMID: 31957042 DOI: 10.1111/nuf.12431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
AIM To develop a simultaneous, evolutionary concept analysis of moral distress and moral uncertainty in the context of medical assistance in dying (MAiD). BACKGROUND Moral distress is well represented in nursing literature but disagreement persists in how the concept is defined and understood. Moral uncertainty has not been investigated in-depth. Further definition and conceptual clarity is required to understand these concepts within the context of MAiD. DESIGN Simultaneous concept analysis. DATA SOURCES Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and PubMed databases were searched for articles in English. The final sample consisted of 44 documents published from 1984 to 2019. METHOD An adapted combination of Rodgers's Evolutionary Model and Haase et al's Simultaneous Concept Analysis method. RESULTS Despite the significant overlap, moral distress and moral uncertainty have subtle distinguishing differences. Attributes of moral distress in the context of MAiD focus on knowing the right course of action but being unable to act, especially when conflict or suffering occurs. Attributes of moral uncertainty center on an inability to decide on which course of action to take or knowing what outcome is preferable. CONCLUSION More research is required to bring further clarity to these concepts and develop interventions to support nurses who receive requests for or participate in MAiD.
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Kalkman JP, Molendijk T. The Role of Strategic Ambiguity in Moral Injury: A Case Study of Dutch Border Guards Facing Moral Challenges. JOURNAL OF MANAGEMENT INQUIRY 2019. [DOI: 10.1177/1056492619892693] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is widespread agreement that lower level organizational members face moral challenges because their personal values conflict with organizational directions. Yet we argue that intentional strategic ambiguity, too, may lead to moral challenges, particularly among organizational members operating in high-stake situations. Drawing on interviews with border guards deployed during the European migration crisis, we use vignettes to present two coping strategies. First, members may disengage from moral challenges and redefine their work as a clear-cut duty. Second, they may embrace moral disorientation and conflicts, and follow felt moral obligations. Both may lead to “moral injury.” Moral injury refers to psychological suffering that is engendered by performing, failing to prevent, or falling victim to actions that conflict with one’s moral belief system. We make three theoretical contributions by (a) identifying the roots of moral challenges in strategic decision-making, (b) signaling different coping mechanisms, and (c) challenging pragmatic perspectives on strategic ambiguity.
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Affiliation(s)
- Jori Pascal Kalkman
- Faculty of Military Sciences, Netherlands Defence Academy (NLDA), Breda, The Netherlands
| | - Tine Molendijk
- Faculty of Military Sciences, Netherlands Defence Academy (NLDA), Breda, The Netherlands
- Centre for International Conflict Analysis & Management, Radboud University (RU), Nijmegen, The Netherlands
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25
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Sullivan S, Germain ML. Psychosocial risks of healthcare professionals and occupational suicide. INDUSTRIAL AND COMMERCIAL TRAINING 2019. [DOI: 10.1108/ict-08-2019-0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to explore compassion fatigue and psychosocial risks among healthcare professionals, which lead to increased work-related costs, including occupational suicide. Through this review and synthesis of the literature, the authors shed light on the causes that lead medical professionals to take their own lives. In addition, the authors explore the role of compassion fatigue as a leading cause of self-inflicted death.
Design/methodology/approach
A systematic approach was used to guide the review and synthesis of the literature. Key bibliographic and review databases were searched from the fields of social work, nursing, medical education, educational leadership, psychology, sociology and human resources.
Findings
In the USA alone, suicide has increased by 25 per cent since 1999, making it a leading cause of death. Data indicate that medical professionals are prone to compassion fatigue, work-related stresses and suicide at a greater rate than the general population, with surgeons reporting up to three times more thoughts of suicide than the general population. The synthesis and analysis of the literature yielded the following themes: compassion fatigue and suicides, burnout and compassion fatigue, career longevity and moral distress.
Research limitations/implications
Job stress and its negative impact on the workforce is rather well documented. Yet, job stress has shown to be a leading cause of workplace suicide, which represents a commensurable human and economic loss and has a direct impact on multiple human resources variables. Ongoing research is needed to see how the initial literature has evolved as new data emerges.
Practical implications
This paper presents best practices for training and development professionals to better respond to psychosocial risks and reduce work-related costs in the medical profession and beyond.
Originality/value
Studies on employee stress and suicide in the healthcare industry are scarce. Yet, they have human and economic impacts on organisations.
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Sanderson C, Sheahan L, Kochovska S, Luckett T, Parker D, Butow P, Agar M. Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/1477750919886088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Christine Sanderson
- Faculty of Health, ImPACCT, University of Technology Sydney, Sydney, Australia
| | - Linda Sheahan
- SE Sydney Local Health District Clinical Ethics Service, Sydney, Australia
| | - Slavica Kochovska
- Faculty of Health, ImPACCT, University of Technology Sydney, Sydney, Australia
| | - Tim Luckett
- Faculty of Health, ImPACCT, University of Technology Sydney, Sydney, Australia
| | - Deborah Parker
- Faculty of Health, Aged Care Nursing, University of Technology Sydney, Sydney, Australia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-Making, University of Sydney, Sydney, Australia
| | - Meera Agar
- Faculty of Health, ImPACCT, University of Technology Sydney, Sydney, Australia
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Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands. Nurs Ethics 2019; 27:1315-1326. [DOI: 10.1177/0969733019877526] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.
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Morley G, Bradbury-Jones C, Ives J. What is 'moral distress' in nursing? A feminist empirical bioethics study. Nurs Ethics 2019; 27:1297-1314. [PMID: 31566094 PMCID: PMC7406988 DOI: 10.1177/0969733019874492] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice. Research aim To explore the concept of moral distress in nursing both empirically and conceptually. Methodology Feminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis. Ethical considerations The study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom. Findings The empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas. Discussion We suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress. Conclusion The empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’.
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Affiliation(s)
- Georgina Morley
- University of Bristol, UK; Barts Health NHS Trust, UK; Cleveland Clinic, US
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Arbe Montoya AI, Hazel S, Matthew SM, McArthur ML. Moral distress in veterinarians. Vet Rec 2019; 185:631. [PMID: 31427407 DOI: 10.1136/vr.105289] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/12/2019] [Accepted: 07/18/2019] [Indexed: 11/03/2022]
Abstract
Moral distress is a psychological state of anguish that has been widely studied in healthcare professionals. Experiencing moral distress can lead to problems including avoidance of patients and increased staff turnover. Moral distress in veterinarians has not yet been explored to the extent seen in the human medical field, and there is limited data regarding moral distress in veterinarians. However, it is expected to be prevalent in these professionals. So far, it has been reported that veterinarians commonly experience moral conflict, ethical challenges and ethical dilemmas during their career. These conflicts in association with other modifying factors such as personality traits can lead to the experience of moral distress. In a profession with known levels of occupational stress and reported mental health problems, exploring the area of moral distress and its effects on the professional wellbeing of veterinarians is important. Further studies such as developing a moral distress scale to measure this issue are needed in order to evaluate the incidence of this problem in veterinary professionals. Furthermore, assessing a possible relationship between moral distress, mental illness and attrition in veterinarians would be useful in developing intervention strategies to minimise the experience of moral distress and its associated negative consequences in veterinarians.
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Affiliation(s)
- Alejandra I Arbe Montoya
- Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - Susan Hazel
- Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
| | - Susan M Matthew
- College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Michelle L McArthur
- Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, South Australia, Australia
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Oakley S, Grealish L, El Amouri S, Coyne E. The lived experience of expatriate nurses providing end of life care to Muslim patients in a Muslim country: An integrated review of the literature. Int J Nurs Stud 2019; 94:51-59. [DOI: 10.1016/j.ijnurstu.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 01/02/2023]
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Abstract
AIMS The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. BACKGROUND Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. DESIGN Systematic literature review and narrative synthesis (November 2015-March 2016). DATA SOURCES Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946-Present, PsycINFO® 1967-Present, CINAHL® Plus 1937-Present, EMBASE 1974-24 February 2016, British Nursing Index 1994-Present, Social Care Online, Social Policy and Practice Database (1890-Present), ERIC (EBSCO) 1966-Present and Education Abstracts. REVIEW METHODS Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. RESULTS In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. CONCLUSION We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.
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Affiliation(s)
- Georgina Morley
- Georgina Morley, Center for Ethics in
Medicine, School of Social and Community Medicine, University of Bristol,
Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
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Sala Defilippis TML, Curtis K, Gallagher A. Conceptualising moral resilience for nursing practice. Nurs Inq 2019; 26:e12291. [PMID: 30817074 DOI: 10.1111/nin.12291] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/26/2022]
Abstract
The term 'moral resilience' has been gaining momentum in the nursing ethics literature. This may be due to it representing a potential response to moral problems such as moral distress. Moral resilience has been conceptualised as a factor that inhibits immoral actions, as a favourable outcome and as an ability to bounce back after a morally distressing situation. In this article, the philosophical analysis of moral resilience is developed by challenging these conceptualisations and highlighting the risks of such limiting perspectives. It is argued that moral resilience is best understood as a virtue with two associated vices, faintheartedness and rigidity. The intellectual virtue of practical wisdom is required to express resilience as a virtue. This understanding leads to recommendations for professional education, for practice and for further research.
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Affiliation(s)
- Tiziana M L Sala Defilippis
- Department of Business Economics, Health and Social Care, University of Applied Sciences of Southern Switzerland, Manno, Switzerland
| | - Katherine Curtis
- Faculty of Health, Social Care and Education, Kingston University & St. George's University of London, Kingston Upon Thames, UK
| | - Ann Gallagher
- International Care Ethics Observatory, School of Health Sciences in the Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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Maffoni M, Argentero P, Giorgi I, Hynes J, Giardini A. Healthcare professionals’ moral distress in adult palliative care: a systematic review. BMJ Support Palliat Care 2019; 9:245-254. [DOI: 10.1136/bmjspcare-2018-001674] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/01/2018] [Accepted: 12/19/2018] [Indexed: 01/08/2023]
Abstract
ObjectivesPalliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care.MethodsA literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms ‘moral distress’ AND ‘palliative care’. The review process has followed the international PRISMA statement guidelines.ResultsThe initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed.ConclusionsCognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.
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Escolar Chua RL, Magpantay JCJ. Moral distress of undergraduate nursing students in community health nursing. Nurs Ethics 2018; 26:2340-2350. [PMID: 30590994 DOI: 10.1177/0969733018819130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students. AIM To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing. RESEARCH DESIGN A descriptive qualitative design was employed to explore the community health nursing experiences of the nursing students that led them to have moral distress. PARTICIPANTS AND RESEARCH CONTEXT The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year. ETHICAL CONSIDERATIONS Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. FINDINGS Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community. CONCLUSION This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the "real world," where the ideals they have will be constantly challenged and tested.
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Applying a Balm: Medicating the Patient to Treat the (Moral) Distress of Caregivers. J Hosp Palliat Nurs 2018; 20:433-439. [PMID: 30188434 DOI: 10.1097/njh.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.
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Hernández-Marrero P, Fradique E, Pereira SM. Palliative care nursing involvement in end-of-life decision-making: Qualitative secondary analysis. Nurs Ethics 2018; 26:1680-1695. [PMID: 29807491 DOI: 10.1177/0969733018774610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nurses are the largest professional group in healthcare and those who make more decisions. In 2014, the Committee on Bioethics of the Council of Europe launched the "Guide on the decision-making process regarding medical treatment in end-of-life situations" (hereinafter, Guide), aiming at improving decision-making processes and empowering professionals in making end-of-life decisions. The Guide does not mention nurses explicitly. OBJECTIVES To analyze the ethical principles most valued by nurses working in palliative care when making end-of-life decisions and investigate if they are consistent with the framework and recommendations of the Guide; to identify what disputed/controversial issues are more frequent in these nurses' current end-of-life care practices. DESIGN Qualitative secondary analysis. PARTICIPANTS/CONTEXT Three qualitative datasets including 32 interviews from previous studies with nurses working in palliative care in Portugal. ETHICAL CONSIDERATION Ethical approval was obtained from the Ethics Research Lab of the Instituto de Bioética (Ethics Research Lab of the Institute of Bioethics) (Ref.04.2015). Ethical procedures are thoroughly described. FINDINGS All participant nurses referred to autonomy as an ethical principle paramount in end-of-life decision-making. They were commonly involved in end-of-life decision-making. Palliative sedation and communication were the most mentioned disputed/controversial issues. DISCUSSION Autonomy was highly valued in end-of-life care and decision-making. Nurses expressed major concerns in assessing patients' preferences, wishes, and promoting advance care planning. Nurses working in palliative care in Portugal were highly involved in end-of-life decision-making. These processes embraced a collective, inclusive approach. Palliative sedation was the most mentioned disputed issue, which is aligned with previous findings. Communication also emerged as a sensitive ethical issue; it is surprising, however, that only three nurses referred to it. CONCLUSION While the Guide does not explicitly mention nurses in its content, this study shows that nurses working in palliative care in Portugal are involved in these processes. Further research is needed on nurses' involvement and practices in end-of-life decision-making.
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Affiliation(s)
| | - Emília Fradique
- Hospital de Santa Maria, Portugal; Instituto S. João de Deus, Portugal
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Abstract
PROBLEM The aim of this concept analysis was to clarify failure to rescure as a nurse-sensitive indicator. Although the concept of failure to rescue as a nurse-sensitive outcome has appeared in the nursing literature for over a decade, conceptual clarity is needed to address its variable and ambiguous use in health care. METHODS Walker and Avant's eight-stage method of concept analysis was used to explore the concept of failure to rescue in nursing practice. Twenty-one papers were retrieved from Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE databases and selected for review and synthesis. RESULTS Failure to rescue as a nurse-sensitive indicator was found to be a "failing to rescue" process characterized by a cascade of events, including four key attributes: (1) errors of omission in care, (2) failure to recognize changes in patient condition, (3) failure to communicate changes, and (4) failures in clinical decision making. CONCLUSIONS Nurses have a pivotal role in "failing to rescue" through early recognition, escalation, and intervention of subtle changes signaling complications. Upstream strategies, such as the use of early warning sign indicators, structured communication, and teamwork, shift the discourse from failure to rescue, to processes in nursing practice of good catch events.
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Affiliation(s)
- Jane Mushta
- Emergency Department, Interior Health Authority, Kelowna, Canada
| | - Kathy L Rush
- School of Nursing, Faculty of Health and Social Development, University of British Columbia, Kelowna, Canada
| | - Elizabeth Andersen
- School of Nursing, Faculty of Health and Social Development, University of British Columbia, Kelowna, Canada
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Alkrisat M. Predict Moral Distress Using Workplace Stress, Stress of Conscience Mediated by Coping Using Roy Adaptation Model: A Path Analysis. J Nurs Meas 2017; 24:477-492. [PMID: 28714452 DOI: 10.1891/1061-3749.24.3.477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Moral distress can be predisposed when nurses are exposed to ambiguous moral situations. PURPOSE Is to test a conceptual model based on Roy adaptation model (RAM) to examine the relationship among workplace stress, conscience stress, and moral distress mediated by coping. DESIGN A correlational, cross sectional. RESULTS Data were collected from 199 licensed nurses. The findings indicated that workplace stress was related negatively to coping processes (β = -.12) and that stress of conscience was predictive of greater use of coping process (β = -.21). CONCLUSION The results indicated that the model suggested based on RAM is saturated and is the perfect fit. However, the alternative models indicated that workplace stress moderately predicted moral distress.
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Abstract
Moral distress is a pervasive problem in nursing resulting in a detriment to patient care, providers, and organizations. Over a decade ago, the moral distress theory (MDT) was proposed and utilized in multiple research studies. This middle range theory explains and predicts the distress that occurs in a nurse because of moral conflict. The research findings born from this theory have been substantial. Since inception of this theory, moral distress has been extensively examined which has further elaborated its understanding. This paper provides an analysis and evaluation of the MDT according to applicable guidelines. Current understanding of the phenomenon indicates that a new theory may be warranted to better predict, treat, and manage moral distress.
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Affiliation(s)
- Melissa A Wilson
- Department, of Aeromedical Research, United States Air Force School of Aerospace Medicine, Fairborn, OH
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Astbury JL, Gallagher CT. Development and validation of a questionnaire to measure moral distress in community pharmacists. Int J Clin Pharm 2016; 39:156-164. [PMID: 28004238 PMCID: PMC5306186 DOI: 10.1007/s11096-016-0413-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/08/2016] [Indexed: 12/03/2022]
Abstract
Background Pharmacists work within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment creates the potential for moral distress to occur due to the limitations it places on acting in congruence with moral judgements. Very little research regarding this phenomenon has been undertaken in pharmacy: thus, prominent research gaps have arisen for the development of a robust tool to measure and quantify moral distress experienced in the profession. Objective The aim of this study was to develop an instrument to measure moral distress in community pharmacists. Setting Community pharmacies in the United Kingdom. Method This study adopted a three-phase exploratory sequential mixed-method design. Three semi-structured focus groups were then conducted to allow pharmacists to identify and explore scenarios that cause moral distress. Each of the identified scenarios were developed into a statement, which was paired with twin seven-point Likert scales to measure the frequency and intensity of the distress, respectively. Content validity, reliability, and construct validity were all tested, and the questionnaire was refined. Main outcome measure The successful development of the valid instrument for use in the United Kingdom. Results This research has led to the development of a valid and reliable instrument to measure moral distress in community pharmacists in the UK. The questionnaire has already been distributed to a large sample of community pharmacists. Conclusion Results from this distribution will be used to inform the formulation of coping strategies for dealing with moral distress.
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Affiliation(s)
- Jayne L Astbury
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, AL10 9AB, UK
| | - Cathal T Gallagher
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, AL10 9AB, UK.
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Campbell SM, Ulrich CM, Grady C. A Broader Understanding of Moral Distress. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:2-9. [PMID: 27901442 DOI: 10.1080/15265161.2016.1239782] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
On the traditional view, moral distress arises only in cases where an individual believes she knows the morally right thing to do but fails to perform that action due to various constraints. We seek to motivate a broader understanding of moral distress. We begin by presenting six types of distress that fall outside the bounds of the traditional definition and explaining why they should be recognized as forms of moral distress. We then propose and defend a new and more expansive definition of moral distress and examine how it can enable the development of a taxonomy of moral distress.
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Wenwen Z, Xiaoyan W, Yufang Z, Lifeng C, Congcong S. Moral distress and its influencing factors: A cross-sectional study in China. Nurs Ethics 2016; 25:470-480. [PMID: 27585462 DOI: 10.1177/0969733016658792] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The purpose of this study was to describe the current situation of moral distress and to explore its influencing factors among Chinese nurses. Methods: This is an exploratory, descriptive design study. A total of 465 clinical nurses from different departments in three Grade-III, Level-A hospitals in Jinan, Shandong Province, completed the questionnaires, including demographics questionnaire, Chinese version of Moral Distress Scale–Revised, and Job Diagnostic Survey. Ethical considerations: The study was approved by the university ethics board and the local health service director. Results: The total score of Moral Distress Scale–Revised was 36.01 ± 24.02 points. The mean frequency and intensity scores of moral distress were 1.13 ± 0.49 and 1.09 ± 0.58, respectively. The level of moral distress among Chinese clinical nurses was low, and the frequency and intensity of moral distress were on low to moderate level. The level of moral distress experienced by clinical nurses is associated with demographics features and job characteristics, including age, education degree, department, task significance, autonomy, and dealing with others. Conclusion: Our conclusion suggests that hospital and organizational administrations should attach much importance to the moral distress experienced by clinical nurses in China. Further studies should focus on interventions about how to reduce the levels of the frequency and intensity of moral distress among clinical nurses.
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Affiliation(s)
| | - Wu Xiaoyan
- Qilu Hospital, Shandong University, China
| | | | - Ci Lifeng
- Qilu Hospital, Shandong University, China
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Abstract
Background: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review Methods: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. Results: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.
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Dahlqvist V, Eriksson S, Glasberg AL, Lindahl E, Lützén K, Strandberg G, Söderberg A, Sørlie V, Norberg A. Development of the Perceptions of Conscience Questionnaire. Nurs Ethics 2016; 14:181-93. [PMID: 17425147 DOI: 10.1177/0969733007073700] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health care often involves ethically difficult situations that may disquiet the conscience. The purpose of this study was to develop a questionnaire for identifying various perceptions of conscience within a framework based on the literature and on explorative interviews about perceptions of conscience (Perceptions of Conscience Questionnaire). The questionnaire was tested on a sample of 444 registered nurses, enrolled nurses, nurses’ assistants and physicians. The data were analysed using principal component analysis to explore possible dimensions of perceptions of conscience. The results showed six dimensions, found also in theory and empirical health care studies. Conscience was perceived as authority, a warning signal, demanding sensitivity, an asset, a burden and depending on culture. We conclude that the Perceptions of Conscience Questionnaire is valid for assessing some perceptions of conscience relevant to health care providers.
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Eisenhauer ER, Arslanian-Engoren C. Religious Values and Biobanking Decisions: An Integrative Review. Res Theory Nurs Pract 2016; 30:104-23. [PMID: 27333632 DOI: 10.1891/1541-6577.30.2.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Biobanking may include research procedures that violate the religious values and preferences of some patients. This integrative literature review evaluated the influence of religious values on participants' decisions to donate biospecimens to biobanks for research. The review followed the method of Whittemore and Knafl (2005). PubMed, CINAHL, and Google Scholar databases were searched for studies published between January 1, 1994 and March 31, 2014. The influence of religious values on decision making in biobanking included the following themes: (a) religious prohibitions, (b) pursuit of health, (c) decisional conflict, and (d) scope of consent. Participants' decisions reflected that they wanted to benefit from scientific advancements and to help others but wanted to do so in accordance with their religious values. The consideration of religious values in decisions about biobanking is an international phenomenon occurring across cultures. Limiting the scope of consent may help to accommodate religious values and preferences. Researchers need to respect the religious values of patients by fully explaining the implications of research procedures in biobanking. Nurses should advocate for the consideration of patients' religious values in this new age of technological advancements.
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Lamiani G, Borghi L, Argentero P. When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates. J Health Psychol 2016. [PMID: 26220460 DOI: 10.1177/1359105315595120] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians' wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.
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Affiliation(s)
- Giulia Lamiani
- 1 University of Milan, Italy.,2 University of Pavia, Italy
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Lievrouw A, Vanheule S, Deveugele M, Vos M, Pattyn P, Belle V, Benoit D. Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies. Oncol Nurs Forum 2016; 43:505-12. [DOI: 10.1188/16.onf.505-512] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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