Moral Distress in Community and Hospital Settings for the Care of Elderly People. A Grounded Theory Qualitative Study

Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies

OBJECTIVE

At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions.

METHODS

A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic.

RESULTS

Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change.

CONCLUSION

This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.

Role of emotions in the clinical decision-making process of the hospital nurse: A multicentre qualitative study

While for a long-time emotional reaction and moral distress, have been primarily investigated for the possible outcomes of the nursing decision-making process rather than in terms of their role as antecedents of the final decision taken. The primary study's aim is to explore how inpatient nurses' decision-making takes place in different care settings, with a special focus on the role played by emotions during decision-making. The secondary aim is to explore the subjective experience of hospital nurses in relation to successful and unsuccessful decision-making situations. Multicentre qualitative study, consisting of three phases with different designs: participatory study, grounded theory study, and phenomenological study. Participants will be nurses and may be doctors with various levels of professional experience working in hospital, outpatient, or ward settings. Participants will be recruited through different sampling (purposive and convenience). Data will be collected through focus groups and in-depth interviews with nurses working in different hospital care settings. The researchers expect to find themes that will contribute to a better understanding of the role of emotions in decision-making. The results of this study have the potential of providing important implications to support nurses in the recognition and management of their emotions during the decision-making process.

Effective Relationships Between Younger Caregivers and Older Care Recipients Across a Continuum of Formal Residential Care Settings: A Scoping Review and a Critical Analysis

Objective: This article aims to conduct a scoping review of what constitutes effective relational interactions between caregivers (CGs) and older persons (OPs) across formal residential care settings. Methods: A scoping review of publications between January 2000 and December 2021 yielded 10,929 articles, and after removing duplicates and applying exclusion criteria, 36 articles were analysed. Results: Articles were scrutinised for interactions involving both CGs and OPs, using a thematic framework analysis to identify effective relational constructs. Four themes emerged: 1) Diverse perspectives on the same context: for OPs it is home, and for CGs, workplace. 2) CGs move for a one-up position and OPs submit to a one-down, or as friends. 3) Relational qualities have been mostly associated with CGs, confirming care as a unidirectional action 4). Relationships between CGs and OPs result either in effective or ineffective care outcomes. Conclusion: The dual meanings attached to the same context limit the authentic interactions between CGs and OPs. We propose a relational caregiving approach by considering the interactions of both CGs and OPs, changing the relational definition, and demonstrating effective relational qualities.

The challenges faced by patients with hereditary myopathy during the COVID-19 pandemic

BACKGROUND

Neuromuscular diseases are inherited and the prevalance of neuromuscular disease is estimated to be around 1:2000.

METHODS

This cross-sectional research was conducted with a qualitative research model. Data were collected from patients with an online survey using the snowball sampling method. The study was conducted in accordance with the STROBE checklist methodology. Frequencies and percentages were used to analyse demographic data, and content analysis was used for qualitative opinions.

RESULTS

Most of the participants were men and their education levels were low. Participants reported experiencing physical and socio-economic barriers to accessing healthcare. Participants also stated that these barriers have worsened since COVID-19.

CONCLUSIONS

Patients with hereditary myopathy are stigmatised by society and face different problems depending on the type of disease and level of function. It is recommended that decision-makers enable patients with hereditary myopathy in exceptional situations to access healthcare services and take steps to resolve their problems.

Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.

How Do Nursing Students Perceive Moral Distress? An Interpretative Phenomenological Study

Background: Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress. The same applies to nursing students. This study aims to analyze episodes of moral distress experienced by nursing students during end-of-life care of onco-hematologic patients in hospital settings. Methods: This study was conducted in the interpretative paradigm using a hermeneutic phenomenological approach and data were analyzed following the principles of the Interpretative Phenomenological Analysis. Results: Seventeen participants were included in the study. The research team identified eight themes: causes of moral distress; factors that worsen or influence the experience of moral distress; feelings and emotions in morally distressing events; morally distressing events and consultation; strategies to cope with moral distress; recovering from morally distressing events; end-of-life accompaniment; internship clinical training, and nursing curriculum. Conclusions: Moral distress is often related to poor communication or lack of communication between health care professionals and patients or relatives and to the inability to satisfy patients’ last needs and wants. Further studies are necessary to examine the quantitative dimension of moral distress in nursing students. Students frequently experience moral distress in the onco-hematological setting.

Elderly Care Practitioners' Perceptions of Moral Distress in the Work Development Discussions

Elderly care practitioners are at specific risk of experiencing prolonged moral distress, which is associated with occupational health-related problems, low job satisfaction, and staff turnover. So far, little attention has been paid to the moral concerns specific to elderly care, a field whose importance is constantly growing as the populations in Western countries age. By drawing on seven workshop conversations as data and interaction-oriented focus group research, conversation analysis and discursive psychology as methods, we aim to study the ways in which elderly care practitioners discuss moral distress in their work. We found that the moral distress experienced was related to three topics that arose when client work and teamwork contexts were discussed: the power to influence, equal treatment of people, and collaboration. The interaction in client work and teamwork contexts differed systematically. The discussion on client work was characterised by negotiations on the rights and wrongs of care work, whereas the teamwork discussion engendered emotional outbursts, a potential manifestation of work-related burnout. Hence, attempts to improve the work-related health of elderly care practitioners require time and space for sharing the emotional load, followed by reflection on what could be improved in the work and what institutional solutions could help in morally distressing situations.

Moral Distress of Intensive Care Nurses: A Phenomenological Qualitative Study Two Years after the First Wave of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has imposed great pressure on healthcare facilities, exposing healthcare professionals to various challenges that may result in the onset of moral distress, a condition of psychological distress caused by the inability to act as it would be most morally appropriate. The purpose of this research was to investigate the experience lived by nurses who worked in an intensive care unit during the COVID-19 pandemic.

METHODS

This is a phenomenological study using interpretative phenomenological analysis. Sixteen nurses who worked in the COVID-19 Intensive Care Unit of Northern Italian Hospitals from January to April 2022 were selected through purposive sampling. Data on experiences, thoughts, and symptoms were collected through semi-structured interviews with in-person and remote modalities.

RESULTS

Five themes and fourteen subthemes emerged from the study. The themes are: (1) pride, isolation, and fear; (2) teamwork and organisation; (3) moral/ethical aspect; (4) true heroes; and (5) dignity.

CONCLUSIONS

This study highlights the impact of the COVID-19 pandemic on intensive care unit nurses. It has emerged that the risk of moral distress is high among healthcare workers in the front line of the fight against the virus. This condition should be avoided and managed through early psychological interventions, sharing of experiences, and a good organization that supports decision-making and professional well-being.

Legal Regulations and the Anticipation of Moral Distress of Prospective Nurses: A Comparison of Selected Undergraduate Nursing Education Programmes

Moral distress is commonly experienced by nurses in all settings. This bears the risk of a reduced quality of care, burnout and withdrawal from the profession. One approach to the prevention and management of moral distress is ethical competence development in undergraduate nursing education. Profession-specific legal regulations function as a foundation for the decision on the educational content within these programmes. This theoretical article presents the extent to which legal regulations may open framework conditions that allow for the comprehensive preparation of prospective nurses to manage moral distress. The legal frameworks and the immediate responsibilities regarding their realisation in the context of undergraduate nursing education vary slightly for the three chosen examples of Switzerland, Austria and Germany. While an increased awareness of ethics’ education is represented within the nursing laws, no definite presumption can be made regarding whether undergraduate nursing students will be taught the ethical competencies required to manage moral distress. It remains up to the curriculum design, the schools of nursing and instructors to create an environment that allows for the realisation of corresponding learning content. For the future, the establishment of professional nursing associations may help to emphasise acutely relevant topics, including moral distress, in undergraduate nursing education.

How smart senior care can achieve value co-creation: Evidence from China

With the rapid rise of artificial intelligence, smart senior care has become a new trend for future development. The collection of "Typical Cases of Chinese Elderly Service Industry Development" is selected by the script materials. The main purpose of this article is to investigate how smart senior care can achieve value co-creation by grounded theory. This study explores the phenomenon of value co-creation in the participation of multiple actors in smart senior care services. Findings show that institutional guarantee, technical intake, market empowerment, emotional support, service interaction, and reciprocity norm are identified as the driving factors for value co-creation. In addition, the behavioral processes of value co-creation include multi-actor value consensus, co-creation environment establishment, practical value co-creation, public value sharing, and diffusion of service added value in smart senior care. Finally, this study constructs a practical logic model of achieving value co-creation. It extends and enriches the scope of the value co-creation theory. This study confirms that value co-creation can be effectively achieved in smart senior care by the above-mentioned ways, revealing its driving factors and behavioral processes. The article expands on the application of value co-creation in the field of public healthcare. The results have important theoretical and practical significance for narrowing the public service equalization gap.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review

BACKGROUND

No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley's instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale-Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress.

METHODS

A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological Abstracts Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle-Ottawa Scale.

RESULTS

Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review's findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores.

CONCLUSIONS

This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Understanding Moral Distress among Eldercare Workers: A Scoping Review

The aging of the population in Western countries will increase the use of social and health services in the future. Employees in eldercare are at risk for experiencing moral distress, which is associated with poor work ability. The causes and consequences of moral distress among eldercare workers remain undiscovered. This scoping review investigates the existing studies of causes and consequences of moral distress among eldercare workers. Additionally, it seeks evidence of interventions designed to mitigate moral distress in eldercare workers. Fourteen studies were included in the final review. Most of the included studies were qualitative, aiming to increase understanding of morally challenging situations in eldercare. We also found quantitative studies with cross-sectional designs and small sample sizes. Thus, no reliable evidence of causal effects between moral distress and worker wellbeing in eldercare was found. We found no interventions undertaken to resolve moral distress among eldercare workers, either. More research is needed on the causes and consequences of moral distress and on interventions to mitigate moral distress among eldercare workers. This is of utmost importance to increase the attractiveness of eldercare as a workplace and to improve eldercare workers’ ability to work and sustain long working careers.

Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy

Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.

Moral Distress Events and Emotional Trajectories in Nursing Narratives during the COVID-19 Pandemic

The COVID-19 pandemic produced several ethical challenges for nurses, impacting their mental health and moral distress. In the moral distress model the categories of events related to moral distress are: constraint, dilemma, uncertainty, conflict, and tension, each one related to different emotions. This study explored moral events' memories and emotions in narratives of a sample of 43 Italian nurses who worked during the COVID-19 pandemic. We constructed an ad-hoc narrative interview asking nurses to narrate the memory, and the associated emotion, of an event in which they felt they could not do the right thing for the patient. We conducted a theory-driven analysis, using the categories proposed by the literature, identifying the main emotion for each category. Results show that 36 memories of events are representative of moral distress; among these, 7 are representative of none of the categories considered, and we categorized them as moral compromise. The main emotional trajectories are powerlessness, worthlessness, anger, sadness, guilt, and helplessness. From a clinical psychological point of view, our findings highlight the narration of the memories of moral events as a tool to use in the ethical sense-making of critical experiences, in order to promote well-being and moral resilience among nurses in emergency situations.

A Psychometric Evaluation of the Family Collaboration Scale and an Investigation of How the Close Family of Frail Older Patients Perceive the Collaboration with Healthcare Professionals on Acute Medical Wards at Hospitals in Sweden

The inclusion of family members in the acute care of older persons with complex needs results in better coordination of care and reduces the frequency and/or duration of rehospitalisation. Therefore, healthcare professionals need a tool to assess the collaboration with family members on acute hospital wards. The aims were to test the psychometric properties of the Swedish version of the Family Collaboration Scale (FCS), to investigate family members' perception of collaboration with healthcare professionals on acute medical wards in Sweden and to compare the data with the corresponding Danish results. Three hundred and sixty family members of frail patients aged 65 or older from 13 acute medical wards answered the FCS questionnaire. In addition to descriptive statistics, psychometric methods were applied. The internal consistency of the Swedish version of the FCS was excellent, and confirmatory factor analysis revealed that its factor structure was equivalent to that of the original Danish FCS. The respondents' ratings indicated better perceived collaboration than in the Danish case. Older age than 60 was associated with worse collaboration with healthcare professionals regarding Influence on discharge than younger respondents. Those with compulsory and health or nursing education showed better collaboration. The Swedish version of the FCS should be further evaluated for its retest reliability and as an outcome measure in intervention studies.

["I am in conflict with myself every day"-Moral distress among geriatric nurses during the COVID-19 pandemic]

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.

Moral Distress Trajectories of Physicians 1 Year after the COVID-19 Outbreak: A Grounded Theory Study

The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians' experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020-February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment.

Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study

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.