Predictors of Moral Distress in a US Sample of Critical Care Nurses

The impact of moral resilience on nurse turnover intentions: the mediating role of job burnout in a cross-sectional study

BACKGROUND

High nursing staff turnover is a critical issue that negatively impacts the quality of care and patient safety. Turnover intentions, a key predictor of actual turnover, reflect an individual's likelihood of leaving their current position. Understanding the underlying mechanisms driving nurse turnover intentions is crucial for developing targeted interventions to stabilize the nursing workforce globally.

OBJECTIVES

This study aims to explore the relationship between moral resilience, job burnout, and turnover intentions among nurses, focusing on the mediating role of job burnout in this relationship.

DESIGN

This study employed a quantitative, cross-sectional design.

METHODS

A convenience sample of 322 registered nurses was recruited from two tertiary hospitals in China between August and October 2023. Data were collected using the Chinese version of the Rushton Moral Resilience Scale (Chi-RMRS), the Maslach Burnout Inventory (MBI), and the Turnover Intention Scale. Data analyses were conducted using SPSS 26.0 and Amos 21.0. The study followed the STROBE guidelines for observational research.

ETHICAL CONSIDERATION

Before the commencement of data collection, the Institutional Review Board of Hunan Traditional Chinese Medical College (YXLL202401004) granted ethical approval.

RESULTS

The proposed model exhibited an excellent fit to the data, with fit indices as follows: χ2/df = 1.819, CFI = 0.977, TLI = 0.961, RMSEA = 0.072 (90% confidence interval [CI]: 0.033 to 0.107). The structural equation model revealed that moral resilience was inversely associated with job burnout and turnover intentions. Furthermore, job burnout fully mediated the relationship between moral resilience and turnover intentions (β = -0.473, p = 0.007). Further analysis indicated that the depersonalization component of job burnout was the sole mediator in the relationship between moral resilience and turnover intention (β = -3.934, 95% CI [-5.837, -1.932]).

CONCLUSION

The findings indicate that moral resilience among nurses is negatively associated with turnover intentions, with this effect fully mediated by the depersonalization dimension of job burnout. Enhancing moral resilience in nurses may be valuable strategy for healthcare administrators to mitigate job burnout and subsequently reduce turnover intentions.

The Effect of Nursing Moral Distress on Intent to Leave Employment

OBJECTIVE

This study explored the impact of moral distress (MD) and respondent characteristics on intent to leave employment.

BACKGROUND

Managing patient care, within organizational constraints, may create physical discomfort or mental peace disturbances such as MD, negatively impacting RN retention.

METHODS

Responses from 948 RNs were collected using an anonymous online survey. The impact of MD on intent to leave employment was explored.

RESULTS

MD was significantly higher among RNs intending to leave employment. System-level and team-level integrity attributes were significant factors predicting intent to leave, controlling for potential confounders. The odds of intending to leave were 147% higher for new graduate RNs, 124% higher for direct care RNs, and 63% higher for 2nd-career RNs. Gender and race were not significant predictors.

CONCLUSION

Exploring root causes contributing to MD frequency and severity is critical to maintain a healthy work environment. Mitigating MD in the work environment may enhance nursing practice and improve patient care. Support for new graduate and 2nd-career RNs can be realized, further reducing turnover for these vulnerable populations of the nursing workforce.

Evaluation of Interventions to Address Moral Distress: A Multi-method Approach

Moral distress is a well-documented phenomenon for health care providers (HCPs). Exploring HCPs' perceptions of participation in moral distress interventions using qualitative and quantitative methods enhances understanding of intervention effectiveness. The purpose of this study was to measure and describe the impact of a two-phased intervention on participants' moral distress. Using a cross-over design, the project aimed to determine if the intervention would decrease moral distress, enhance moral agency, and improve perceptions about the work environment. We used quantitative instruments and explored participants' perceptions of the intervention using semi-structured interviews. Participants were from inpatient settings, within three major hospitals of a large, urban healthcare system in the Midwest, United States. Participants included nurses (80.6%) and other clinical care providers. Using generalized linear mixed modeling we assessed the change in each of the outcome variables over time controlling for groups. Interviews were audiotaped and professionally transcribed. The written narratives were coded into themes. The change in scores on study instruments trended in the desired direction however did not meet statistical significance. Qualitative interviews revealed that intervention effectiveness was derived from a combination of learning benefits, psychological benefits, and building community that promoted moral agency. Findings demonstrate a clear link between moral distress and moral agency and suggest that Facilitated Ethics Conversations can enhance the work environment. Findings provide insight for developing evidenced-based approaches to address moral distress of hospital nurses.

Development of burnout and moral distress in intensive care nurses: An integrative literature review

AIMS

To describe, through an integrative literature review, the factors contributing to the development of burnout and moral distress in nursing professionals working in intensive care units and to identify the assessment tools used most frequently to assess burnout and moral distress.

METHODS

An integrative literature review was carried out. PubMed, CINAHL, PsycINFO, SciELO, Dialnet, Web of Science, Scopus, and Cochrane databases were reviewed from January 2012 to February 2023. Additionally, snowball sampling was used. The results were analysed by using integrative synthesis, as proposed by Whittemore et al., the Critical Appraisal Skills Programme for literature reviews, the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for quantitative observational studies, and the Joanna Briggs Institute checklist for qualitative research were used to evaluate evidence quality.

RESULTS

Forty-one articles were selected for review: 36 were cross-sectional descriptive articles, and five were literature reviews. The articles were grouped into five-factor categories: 1) personal factors, 2) organisational factors, 3) labour relations factors, 4) end-of-life care factors, and 5) factors related to coronavirus disease 2019 (COVID-19). The Maslach Burnout Inventory-Human Services Survey and the Moral Distress Survey-Revised instruments were the most commonly used to measure burnout and moral distress.

CONCLUSIONS

This review highlights the multiple personal, organisational, relational, situational, and end-of-life factors promoting burnout and moral distress among critical care nurses. Interventions in these areas are necessary to achieve nurses' job satisfaction and retention while improving nurses' quality of care.

Factors contributing to moral distress among intensive care nurses: A scoping review

Background: The intensive care unit (ICU) is a busy and complex workplace, and several work-related and personal factors are known to make ICU nurses more vulnerable to moral distress than other healthcare professionals. It is crucial to identify these factors to guide future studies and preventive strategies. This scoping review explores such factors to present current knowledge on the factors that trigger moral distress and to guide future research by reviewing studies to explore and summarize factors that trigger moral distress in ICU nurses. Methods: The PubMed, EBSCO, and CINAHL Plus databases were searched to identify potentially relevant studies published between 2011 to 2022. Inclusion criteria: peer-reviewed studies published in English that provided results regarding factors causes or correlated to moral distress in ICU nurses. After removing 618 duplicates, 316 papers were excluded after title and abstract screening, leaving 71 articles for full-text screening. A further 54 articles were excluded as their outcomes did not include factors that caused moral distress, or were not specific to ICU nurses, so 17 studies were eventually analysed using qualitative content analysis through an inductive approach. The findings of the articles were extracted and coded independently by two authors, and data were grouped and categorized. Results: The content categories of factors contributing to ICU nurses' moral distress were organized into themes and subthemes. Four major themes were identified: Powerlessness, end-of-life care, ineffective teamwork, and personal characteristics of ICU nurses. Conclusions: This review highlights the factors that contribute to moral distress in critical care nurses, which are mainly attributable to the organizational climate and the nature of the ICU clinical environment. Descriptive and intervention studies (experimental or action research) must investigate causality between identified variables to inform management strategies to improve support for ICU nurses' coping relative to moral distress.

Psychological distress symptoms in nurses and their intention to leave: A cross-sectional secondary data analysis

AIM

This study aimed to examine the psychological symptoms of distress among nurses in relation to their intention to leave.

DESIGN

This study was a secondary data analysis of a cross-sectional survey collected between November 2020 and March 2021.

METHODS

Chi-square was used to examine the associations between the demographic characteristics and intention to leave and psychological distress symptoms-feeling depressed, anxious and worried. Multiple linear regression analyses were performed to examine if work settings, position (staff, charge, administrators, educators/researchers and advanced practice registered nurses) and years of experience were associated with psychological distress and intention to leave. A mediation analysis examined if psychological distress mediated the relationship between years of experience and intention to leave.

RESULTS

Overall, psychological distress was significantly positively associated with intention to leave and negatively associated with years of experience. Nurses with less than 2 years of experience had increased psychological distress, while nurses with >25 years of experience had decreased psychological distress. Both groups of nurses had increased intention to leave compared to those with 16-25 years of experience. Psychological distress partially mediated intention to leave in nurses with less than 2 years of experience and more so among nurses with >25 years of experience.

CONCLUSIONS

This study suggests that nurses encounter psychological distress symptoms, such as feeling anxious, depressed and worried, that contribute to an increased intention to leave. Among the workplace locations, nurses practicing in nursing homes had the highest intention to leave.

IMPACT

The study emphasizes that organizations need to focus on mitigating distress across all levels of nurses to promote retention efforts and intention to stay.

REPORTING METHOD

The authors adhered to the STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient contribution. Completion of the survey in the original study (NWWS) implied consent from the participating nurses.

Moral distress among critical care nurses before and during the COVID-19 pandemic: A systematic review

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care.

'Sit down and thrash it out': opportunities for expanding ethics consultation during conflict resolution in long-term care

OBJECTIVE

To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution.

DESIGN

An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA).

RESULTS

Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance.

CONCLUSION

Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.

Intent to stay, moral distress, and nurse practice environment among long-term care nurses: A cross-sectional questionnaire survey study

BACKGROUND

Many long-term care facilities in the United States face significant problems with nurse retention and turnover. These challenges are attributed, at least in part, to moral distress and a negative nurse practice environment.

OBJECTIVE

The purpose of the study was divided into two parts: first, to investigate the relationships among nurse practice environment, moral distress, and intent to stay; second, to explore the potential mediating effect of the nurse practice environment on the intent to stay among those with high levels of moral distress.

DESIGN

This study was a descriptive, cross-sectional survey using targeted sampling.

PARTICIPANTS

A total of 215 participants completed the surveys. Participants were nationally representative of long-term care nurses by age, years of experience, employment status, and type of health setting.

METHODS

This study was an online national survey of long-term care nurses' perceptions of their intent to stay, moral distress level (Moral Distress Questionnaire), and nurse practice environment (Direct Care Staff Survey). Structural equation modeling analysis explored intent to stay, moral distress, and the nurse practice environment among long-term care nurses.

RESULTS

The mean moral distress score was low, while the mean nurse practice environment and intent to stay scores were high. Moral distress had a significant, moderately negative association with the nurse practice environment (β = -0.41), while the nurse practice environment had a significant, moderately positive association with intent to stay (β = 0.46). The moral distress had a significant, moderately negative association with intent to stay (β = -0.20). The computed structural equation modeling suggested a partially mediated model (indirect effect = -0.19, p = 0.001).

CONCLUSION

Since the nurse practice environment partially mediates the relationship between moral distress and intent to stay, interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.

CLINICAL RELEVANCE

Our study demonstrated that the nurse practice environment mediates moral distress and intent to stay. Interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.

Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals

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.

The Impact of Moral Distress on Staff and Novice Nurses

ABSTRACT

Moral distress is an interior affliction associated with exterior conflicts between one's values, obligations, and actions. This article builds understanding of moral distress among nurses and the importance of reducing its harmful impact, particularly to novice nurses. Moral distress is defined along with ethical issues and concepts related to moral distress, its current impact, coping with moral distress and building moral reserve, and the significance of acting according to one's conscience.

Examining moral injury in clinical practice: A narrative literature review

Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included "moral injury" and "moral distress," identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs.

Moral distress among nurse leaders: A qualitative systematic review

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and APA PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions.

Levels of burnout and exposure to ethical conflict and assessment of the practice environment in nursing professionals of intensive care

BACKGROUND

Nursing professionals working in Intensive Care Units (ICU) are at high risk of developing negative emotional responses as well as emotional and spiritual problems related to ethical issues. The design of effective strategies that improve these aspects is determined by knowing the levels of burnout and ethical conflict of these professionals, as well as the influence that the practice environment might have on them.

OBJECTIVES

To analyze the relationship between levels of burnout, the exposure to ethical conflicts and the perception of the practice environment among themselves and with sociodemographic variables of the different intensive care nursing professionals.

METHODS

Descriptive, correlational, cross-sectional, observational study in an ICU of a tertiary level university hospital. The level of burnout was evaluated with the Maslach Burnout Inventory Human Services Survey scale; the level of ethical conflict with the Ethical Conflict Questionnaire for Nurses and the perception of the environment with the Practice Environment Scale of the Nursing Work Index. Descriptive and inferential statistics were performed. The association between categorical variables was analyzed using Fisher's exact chi-square test (χ2) RESULTS: 31 nurses and 8 nursing assistants were evaluated, which meant a participation rate of 82,93%. 31,10% of the nursing professionals presented signs of burnout, 14,89% considered that they work in an unfavorable environment and 87,23% presented a medium-high index of exposure to ethical conflict. The educational level (χ2=11.084, p=0.011) and the professional category (χ2=5.007, p=0.025) influenced the level of burnout: nursing assistants presented higher levels of this. When comparing the level of burnout with the environment and the index of ethical conflict, there were no statistically significant differences.

CONCLUSIONS

The absence of association found in the study between Burnout and ethical conflict with the perception of the practice environment suggests that personal factors may influence its development.

Moral distress in long-term care questionnaire modification and psychometric evaluation

BACKGROUND

Licensed nurses working in long-term care facilities experience ethical challenges if not resolved can lead to moral distress. There is a lack of an English-language validated tool to adequately measure moral distress in the long-term care setting.

AIMS

To describe the modification and psychometric evaluation of the Moral Distress Questionnaire.

METHODS

Instrument development and psychometric evaluation. Internal consistency using Cronbach's α to establish reliability was conducted using SPSS version 27.0 while SPSS Amos version 27.0 was used to perform a confirmatory factor analysis of the Moral Distress Questionnaire.

PARTICIPANTS

A national sample of US-licensed nurses who provided direct resident care in long-term care settings were recruited via a targeted sampling method using Facebook from 7 December 2020 to 7 March 2021.

ETHICAL CONSIDERATION

The study was approved by the university's human research protection program. Informed consent was provided to all participants.

RESULTS

A total of 215 participants completed the surveys. Confirmatory analysis indicated that the 21-item scale with a 4-factor structure for the Moral Distress Questionnaire model met the established criteria and demonstrates an acceptable model fit (CMIN/DF = 2.0, CFI = 0.82, TLI = 0.77, RMSEA = 0.07). Factor loadings for each item depict a moderate to a strong relationship (range 0.36-0.70) with the given underlying construct. Cronbach's α coefficient was 0.87 for the overall scale and 0.60-0.74 for its subscales which demonstrate good reliabilities.

DISCUSSION

This is the first English-language validated tool to adequately measure moral distress in the long-term care setting experienced by US long-term care nurses. This reliable and well-validated tool will help identify moral distress situations experienced by US long-term care nurses.

CONCLUSION

The modified 21-item English version of the Moral Distress Questionnaire is reliable tool that demonstrates good psychometric properties to validly measure sources of moral distress among direct resident care nurses.

Ethics and frontline nursing during COVID-19: A qualitative analysis

BACKGROUND

Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses' experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts.

RESEARCH AIM

To analyze frontline U.S. nurses' experiences of ethics during the COVID-19 pandemic.

RESEARCH DESIGN

Qualitative analysis using a directed content methodology.

PARTICIPANTS AND RESEARCH CONTEXT

The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States.

ETHICAL CONSIDERATIONS

Participant privacy and data confidentiality were addressed.

FINDINGS

Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients.

DISCUSSION

This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice.

CONCLUSIONS

Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed-methods systematic review and thematic synthesis

AIM

To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well-being and professional and career intentions.

DESIGN

Joanna Briggs Institute mixed-methods systematic review and thematic synthesis. Registered in Prospero (Redacted).

METHODS

Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction.

RESULTS

Searches yielded 2343 hits. Seventy-seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well-being.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Moral Distress in the ICU: Measuring, Tracking, and Responding to Staff Experiences

Until the surges of COVID-19 patients overwhelmed our health care system, moral distress was largely unknown outside of health care. We conducted a study in a 36-bed intensive care unit (ICU) over an 8-week period to determine the severity and contributing factors to clinicians' moral distress and how their moral distress impacted intent to leave, and to assess utilization of resources to mitigate the problem. This article describes the level of moral distress experienced by ICU staff, the disparity between hospital-provided resources and the contributing factors of moral distress, and the potential financial cost of job turnover due to moral distress.

Effect of a Moral Distress Consultation Service on Moral Distress, Empowerment, and a Healthy Work Environment

BACKGROUND

 Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed.

OBJECTIVE

 To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation.

METHODS

 A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale.

RESULTS

 Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment.

CONCLUSIONS

 Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness.

Moral distress: Does this impact on intent to stay among adult critical care nurses?

BACKGROUND

Moral distress is recognized as an international problem that contributes to decreased work productivity, job dissatisfaction and intent to leave for adult Critical Care nurses.

AIM

To explore Critical Care nurses moral distress levels using the Moral Distress Scale Revised (MDS-R) and its relationship with intention to stay. The study reported in this paper was part of a larger study that also investigated Critical Care nurses' work environment in Canada and the Midlands region of the UK.

STUDY DESIGN

During January to August 2017 a cross-sectional survey was distributed to adult Critical Care nurses in the Midlands region of the UK.

METHODS

Surveys were distributed to adult Critical Care Registered Nurses in the Midlands region of the UK examining moral distress levels and intention to stay in Critical Care, the organization (NHS Trust) and in the nursing profession.

RESULTS

Two hundred sixty-six number of a potential sample of 1066 Critical Care nurses completed the survey (25% response rate). Age and moral distress were significantly positively correlated with intention to stay on their current unit (r = 0.16, P = .05), indicating older nurses were more likely to stay in the critical care unit. Moral distress was negatively correlated with intent to stay scores, showing critical care nurses with higher levels of moral distress were less likely to stay on their unit (r = -0.20, P = .02). Moral distress was also significantly negatively correlated with intention to stay with their current employer (r = -0.28, P < .001). Nurses that stated they had high rates of moral distress were more likely to consider leaving their current employer.

CONCLUSION

Moral distress appears to be an issue among adult Critical Care nurses requiring further exploration and development of effective strategies to reduce this phenomenon and stabilize the workforce by reducing turnover.

RELEVANCE TO CLINICAL PRACTICE

By identifying the top causes of moral distress, tools and strategies can be developed to allow the Critical Care nurse to work within an ethically safe clinical environment and reduce the turnover of experienced adult Critical Care nurses.

Moral distress during COVID-19: The importance of perceived organizational support for hospital nurses

Moral distress, or the inability to act congruent with moral beliefs, has been of concern for healthcare professionals especially since the COVID-19 pandemic. Hospital nurses are particularly affected in their roles with mounting administrative pressures and demands. We examined whether general and COVID-specific support in employing healthcare organizations predicted moral distress in a sample of inpatient hospital nurses. A total of 248 nurses completed the Measure of Moral Distress for Healthcare Professionals, Survey of Perceived Organizational Support, COVID Organizational Support survey, and the Hospital Ethical Climate Scale. We found that general and COVID-related organizational support were predictors of moral distress after controlling for age, gender, working in an intensive care unit setting, and ethical climate. Findings support the need for a comprehensive strategy to address moral distress, including institutional efforts to convey support and commitment. Strategies moral distress may be experienced differently based on gender identity.

Identifying Sources of Moral Distress Amongst Critical Care Staff During the Covid-19 Pandemic Using a Naturalistic Inquiry

Introduction

Moral distress can have a significant impact on the mental health and well-being of practitioners. Causes of moral distress in critical care have been identified as futile treatment, conflict between family members and staff, lack of resources, and dysfunctional teams.

Objectives

This study explores the sources of moral distress during the COVID-19 pandemic and the meaning that staff attached to these events. The study aims to examine whether the sources of moral distress are similar, or different, to those that commonly occur in critical care departments.

Methods

Naturalistic inquiry using semi-structured individual interviews with 17 participants drawn from nursing ( n = 12), medicine ( n = 3), and the allied health professions ( n = 2). The interviews were recorded and transcribed verbatim. The transcripts were analyzed using reflexive thematic analysis.

Results

The results suggested that while there were some similar sources of moral distress including caring for dying patients and not being able to provide the usual standard of care, the nature of the disease trajectory and frequency of death had a significant impact. In addition, the researchers found that providing care which was counter-intuitive, concerns about the risks to the staff and their families and the additional burdens associated with leading teams in times of uncertainty were identified as sources of moral distress.

Conclusion

This study explored the potential sources of moral distress during the pandemic and the meaning that practitioners attached to their experiences. There were some similarities with the sources of moral distress in critical care which occur outside of a pandemic. However, the frequency and intensity of the experiences are likely to be different during a pandemic, with staff describing high volumes of deaths without family members present. In addition, new sources of moral distress related to uncertainty, counter-intuitive care and concerns about personal and family risk of infection were identified.

Interventions to Reduce Nurses' Moral Distress in the Intensive Care Unit: An Integrative Review

BACKGROUND

Critical care nurses experience moral distress, the phenomenon of knowing the "right" thing to do but being unable to do so, at high rates; this contributes to attrition and has severe mental health impacts on nurses.

OBJECTIVE

The purpose of this integrative review was to determine if interventions to reduce moral distress have an effect on intensive care unit (ICU) nurses' moral distress levels.

METHODS

Three databases were searched, PubMed, APA PsycNet, and CINAHL, using the keywords "moral distress" AND nurs* AND reduc* AND ("intensive care" OR "critical care" OR ICU). Only experimental studies involving adult ICU nurses were included for a total of 6 studies.

RESULTS

Interventions fell into 3 categories: (1) educational interventions, (2) interventions to enhance the ICU environment, and (3) interventions to help nurses cope. Two studies detailing educational interventions demonstrated some reduction in moral distress. One study aimed to improve the ICU environment and showed some statistically significant reduction in moral distress. All 6 studies included some focus on coping, and 2 showed statistically significant reductions in moral distress.

DISCUSSION

Only a few studies have been conducted examining this issue. These studies had severe limitations, such as small sample sizes, attrition, and inadequate control groups. There were also few statistically significant results. These interventions should be reexamined using larger sample sizes, and other interventions should also be trialed. COVID-19 may have had a significant impact on this issue, and interventions may need to be refocused in the wake of the pandemic.

Development and Preliminary Psychometric Testing of the Drake Atrial Electrogram Assessment Survey: DAEGAS

BACKGROUND

Critical care nurses who care for postoperative cardiac surgery patients need such specialty knowledge as atrial electrograms (AEGs). An inadequate audit trail exists for psychometric performance of instruments to measure knowledge of AEGs.

OBJECTIVES

The aim of this study was to revise a previously tested instrument and assess evidence for content validity (content validity index), internal consistency (Cronbach α), and stability (correlation coefficient, r) reliability against the a priori criterion of 0.80.

METHODS

The multiple-choice response, self-administered, paper-and-pencil instrument was revised to 20 items and named the Drake Atrial Electrogram Assessment Survey (DAEGAS). A panel of 6 AEG experts reviewed the DAEGAS for content validity evidence. The instrument was further revised to 19 items (13 knowledge and 6 AEG interpretation) and tested with 76 critical care nurses from the greater Houston metropolitan area.

RESULTS

The content validity index was 0.93. Cronbach α was .51, and test-retest r was 0.74. Cronbach α increased to .60 and r was 0.73 with removal of 3 items: 2 items with a negative item-total correlation and 1 item that was transitioned to a sample question.

DISCUSSION

Content validity evidence exceeded the a priori criterion. Internal consistency and stability reliability estimates did not meet the criterion, albeit the latter met the criterion recommended by psychometricians for a new instrument. Recommendations include further development of the DAEGAS to improve internal consistency estimates and testing for evidence of other forms of validity. Reliable and valid assessment of critical care nurse knowledge of AEGs will require improved psychometric performance of the DAEGAS.

Moral distress in clinical research nurses

Background: Clinical research nurses experience unique challenges in the context of their role that can lead to conflict and moral distress. Although examined in many areas, moral distress has not been studied in clinical research nurses.Research aim: The aim of this study was to examine moral distress in clinical research nurses and the relationship between moral distress scores and demographic characteristics of clinical research nurses.Research design: This was a descriptive quantitative study to measure moral distress in clinical research nurses using the Measure of Moral Distress - Healthcare Professionals (MMD-HP) administered electronically. Demographic data were also collected.Participants and research context: Registered nurses working in the clinical research nurse role (N = 322) were recruited through use of social media, emails, digital flyers, and snowball recruitment. Data was analyzed using SPSS. Pearson's correlation, independent t-test, and one-way ANOVA were performed to explore differences among the demographic variables.Ethical considerations: This study was approved by the Institutional Review Board at Texas Woman's University. A consent statement was included, and completion of the questionnaire was construed as consent.Findings/results: Analysis revealed a mean overall moral distress score of 79.58 (SD = 64.27) and median of 67, with a range of 0-354. Moral distress scores were negatively correlated with clinical research nurse age (r = 0-.156, p < 0.05). Reliability of the MMD-HP was demonstrated with a Cronbach's alpha of 0.93.Conclusions: The findings demonstrate that clinical research nurses do experience moral distress and revealed a wide range of scores. Further research is necessary to determine potential patient impact due to moral distress and to develop processes to minimize moral distress in the clinical research setting. This study was conducted during the COVID-19 pandemic, and the digital recruitment methods proved effective in recruiting a wide range of clinical research nurses, both nationally and internationally.

Moral distress, emotional impact and coping in intensive care unit staff during the outbreak of COVID-19

BACKGROUND

From the beginning, the COVID-19 pandemic increased ICU workloads and created exceptionally difficult ethical dilemmas. ICU staff around the world have been subject to high levels of moral stress, potentially leading to mental health problems. There is only limited evidence on moral distress levels and coping styles among Spanish ICU staff, and how they influenced health professionals' mental health during the pandemic.

OBJECTIVES

To assess moral distress, related mental health problems (anxiety and depression), and coping styles among ICU staff during the first wave of the COVID-19 pandemic in Spain.

DESIGN

Cross-sectional.

SETTINGS AND PARTICIPANTS

The study setting consisted of intensive care unit and areas converted into intensive care units in public and private hospitals. A total of 434 permanent and temporary intensive care staff (reassigned due to the pandemic from other departments to units) answered an online questionnaire between March and June 2020.

METHODS

Sociodemographic and job variables, moral distress, anxiety, depression, and coping mechanisms were anonymously evaluated through a self-reported questionnaire. Descriptive and correlation analyses were conducted and multivariate linear regression models were developed to explore the predictive ability of moral distress and coping on anxiety and depression.

RESULTS

Moral distress during the pandemic is determined by situations related to the patient and family, the intensive care unit, and resource management of the organisations themselves. intensive care unit staff already reached moderate levels of moral distress, anxiety, and depression during the first wave of the pandemic. Temporary staff (redeployed from other units) obtained higher scores in these variables (p = 0.04, p = 0.038, and p = 0.009, respectively) than permanent staff, as well as in greater intention to leave their current position (p = 0.03). This intention was also stronger in health staff working in areas converted into intensive care units (45.2%) than in normal intensive care units (40.2%) (p = 0.02). Moral distress, coupled with primarily avoidance-oriented coping styles, explains 37% (AdR2) of the variance in anxiety and 38% (AdR2) of the variance in depression.

CONCLUSIONS

Our study reveals that the emotional well-being of intensive care unit staff was already at risk during the first wave of the pandemic. The moral distress they experienced was related to anxiety and depression issues, as well as the desire to leave the profession, and should be addressed, not only in permanent staff, but also in temporary staff, redeployed to these units as reinforcement workers.

Moral distress and moral resilience of nurse managers

BACKGROUND

Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience.

AIM

The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil.

RESEARCH DESIGN

The research design is the qualitative study with discursive textual analysis.

PARTICIPANTS AND RESEARCH CONTEXT

: 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions.

ETHICAL CONSIDERATIONS

The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity.

FINDINGS

Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation.

CONCLUSION

From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience.

Moral Distress Experienced by US Nurses on the Frontlines During the COVID-19 Pandemic: Implications for Nursing Policy and Practice

Introduction

The ongoing COVID-19 pandemic represents the largest contemporary challenge to the nursing workforce in the 21^st century given the high stress and prolonged strain it has created for both human and healthcare supply resources. Nurses on the frontlines providing patient care during COVID-19 have faced unrivaled psychological and physical demands. However, no known large-scale qualitative study has described the emotions experienced by nurses providing patient care during the first wave of the COVID-19 pandemic in the US. Objective: Therefore, the purpose of this study was to qualitatively describe the emotions experienced by US nurses during the initial COVID-19 pandemic response.

Methods

One hundred individual interviews were conducted with nurses across the United States from May to September of 2020 asking participants to describe how they felt taking care of COVID-19 patients. All interviews followed a semi-structured interview guide, were audio recorded, transcribed, verified, and coded by the research team.

Results

Participants narratives of the emotions they experienced providing patient care during COVID-19 unequivocally described (1) moral distress, and moral distress related (1.1) fear, (1.2) frustration, (1.3) powerlessness, and (1.4) guilt. In sum, the major emotional response of nurses across the US providing patient care during the pandemic was that of moral distress.

Conclusion

Investments in healthcare infrastructures that address moral distress in nurses may improve retention and reduce burnout in the US nursing workforce.

Moral distress interventions: An integrative literature review

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Impact of Nurse-Physician Collaboration, Moral Distress, and Professional Autonomy on Job Satisfaction among Nurses Acting as Physician Assistants

Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this study was to verify the impact of nurse-physician collaboration, moral distress, and professional autonomy on job satisfaction among nurses acting as physician assistants. Descriptive and correlational research was conducted on a convenience sample of 130 nurses from five general hospitals in South Korea. In the final regression model, the adjusted R square was significant, explaining 38.2% of the variance of job satisfaction (F = 8.303, p < 0.001), where 'cooperativeness' (β = 0.469, p = 0.001) from nurse-physician collaboration, 'institutional and contextual factor' from moral distress (β = -0.292, p = 0.014), and professional autonomy (β = 0.247, p = 0.015) were included. In hospital environments, a more cooperative inter-professional relationship between nurses and physicians led to less moral distress caused by organisational constraints. A higher level of professional autonomy among nurses acting as physician assistants is required to increase their job satisfaction.

Relationship Between Moral Distress and Intent to Leave a Position Among Neonatal Intensive Care Nurses

BACKGROUND

The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses.

PURPOSE

To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey.

METHODS

A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020.

FINDINGS

A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress.

IMPLICATIONS

for Practice: NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses.

IMPLICATIONS FOR RESEARCH

Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.

Moral Distress Among Interdisciplinary Critical Care Team Members at a Comprehensive Cancer Center

BACKGROUND

Moral distress (MD) has been linked to health care professional burnout, intent to leave, and decreased quality of care.

OBJECTIVES

The aim of this study was to describe the perceptions of MD among critical care interdisciplinary team members and assess the association of MD with team member characteristics.

METHODS

A descriptive cross-sectional design was used with interdisciplinary team members in an intensive care unit setting at an NCI-designated Comprehensive Cancer Center in the southeastern United States. The Measure of Moral Distress for Healthcare Professionals was provided to registered nurses, oncology technicians, providers, respiratory therapists, and ancillary team members (social workers, pharmacists, dietitians).

RESULTS

A total of 67 team members completed the survey. Mean responses for 3 items were higher than 8 (halfway point of scale): "Follow family's insistence to continue aggressive treatment even though I believe it is not in the best interest of patient" (mean [SD], 11.4 [4.8]); "Continue to provide aggressive treatment for a patient most likely to die regardless of this treatment when no one will make a decision to withdraw it" (mean [SD], 10.5 [5.3]); and "Witness providers giving 'false hope' to patient/family" (mean [SD], 9.0 [5.3]). Higher responses on the "Continuing to provide aggressive treatment" item was associated with having "considered leaving due to MD" (P = .027) and "considering leaving now due to MD" (P = .016). Higher total scores were related to having left or considered leaving a job (P = .04). When examining education level, registered nurses with a master's degree (n = 5) exhibited the most MD (P = .04).

CONCLUSION

This study suggests that the Measure of Moral Distress for Healthcare Professionals is useful in identifying areas for focused efforts at reducing MD for interdisciplinary teams.

Nurse Graduates' Perceived Educational Needs After the Death of a Patient: A Descriptive Qualitative Research Study

BACKGROUND

Nurse graduates (NGs) are ill prepared when faced with patient death and dying, despite receiving educational preparation on end-of-life (EOL) care in their prelicensure nursing programs.

METHOD

This qualitative descriptive study included a convenience sample of NGs (n = 20) who experienced a first adult patient death during their first 18 months of practice at a large teaching hospital with an extensive NG transition program, including preceptor-guided orientations, nurse internship programs, and nurse residency programs.

RESULTS

Six major themes described the NG experience: Navigating the Process, Not Prepared, Support, Missed Opportunities, Preparing NGs for Death and Dying, and Guiding NGs Through Practice. Critical gaps in preparation were evident across all themes.

CONCLUSION

Results of this study suggest specific opportunities for improvement of NGs' readiness to effectively care for patients and families in EOL situations by increasing their exposure to death and dying experiences before graduation and during their first year of practice. [J Contin Educ Nurs. 2020;50(6):267-273.].

Changing nursing practice in response to musculoskeletal l pain and injury in the emergency nursing profession: What are we missing?

BACKGROUND

Musculoskeletal disorders in emergency nurses result in physical, psychological and financial strain. Contributing factors include: environmental, organisational, patient-related, medical emergencies, nurse's knowledge and health status. Stress and moral distress impact on nurses changing manual handling practices.

METHODS

Part of a cross-sectional survey of Australian emergency nurses, this study used content analysis to identify occurrence of change to practice and enablers to reporting injury. Secondary interpretive analysis using moral distress theory informed an alternative understanding of why nurses may not change their practice in response to injury.

RESULTS

Most respondents made practice changes and reported pain/injury; 23% did not change, and 45.7% did not report. Respondents considered change impossible due to high demands and lack of resources; a position where nurses may have felt pressured to carry out unsafe manual handling practices. When conflicted between reporting a perceived insignificant injury, with feelings of guilt, nurses can feel devalued. Moral distress can occur when nurses and managers are conflicted between providing care and caring for self.

CONCLUSIONS

A culture of trust, respect and open communication decreases stress/moral distress, enables safer manual handling and reporting of pain/injury. Moral distress is an invisible workplace challenge that needs to be met for staff wellbeing.

Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community

Burnout incurs significant costs to health care organizations and professionals. Mattering, moral distress, and secondary traumatic stress are personal experiences linked to burnout and are byproducts of the organizations in which we work. This article conceptualizes health care organizations as moral communities-groups of people united by a common moral purpose to promote the well-being of others. We argue that health care organizations have a fundamental obligation to mitigate and prevent the costs of caring (eg, moral distress, secondary traumatic stress) and to foster a sense of mattering. Well-functioning moral communities have strong support systems, inclusivity, fairness, open communication, and collaboration and are able to protect their members. In this article, we address mattering, moral distress, and secondary traumatic stress as they relate to burnout. We conclude that leaders of moral communities are responsible for implementing systemic changes that foster mattering among its members and attend to the problems that cause moral distress and burnout.

Moral distress among nurses: A mixed-methods study

BACKGROUND

Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand.

OBJECTIVE

This study aims to describe the experience of moral distress and related factors among Thai nurses.

DESIGN

A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated.

PARTICIPANTS

Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand.

ETHICAL CONSIDERATIONS

This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151.

RESULTS

A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress.

DISCUSSION

Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient's and family's religious perspective that ties into the concept of moral distress needs to be explored.

CONCLUSIONS

Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context.

Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals

OBJECTIVES

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP).

METHODS

We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted.

RESULTS

308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument.

CONCLUSIONS

The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.

A cross-sectional exploration of emergency department nurses' moral distress, ethical climate and nursing practice environment

INTRODUCTION

Moral distress is a common phenomenon among nurses that leads to physical and emotional problems and affects job retention, job satisfaction, and quality of care.

AIM

To explore relationships between moral distress, ethical climate, and nursing practice environment among a sample of ED nurses and determined significant predictors of moral distress in organizational environments.

METHODS

A cross-sectional descriptive and correlational survey was performed on 237 nurses in emergency departments (EDs) from five hospitals in Taiyuan, mainland China.

RESULTS

Statistically significant negative and moderate correlations were found between the level of moral distress and ethical climate for the overall evaluation and 10 subscale scores and the overall evaluation of the nursing practice environment. The nurse-physician collaboration, ethical climate, and monthly income were statistically significant predictors of the level of moral distress (change in R² = 17.9%, 5.5%, and 5.6%, respectively).

CONCLUSIONS

Perceptions of a more positive ethical climate and healthier nursing practice environment resulted in lower moral distress levels experienced by ED nurses. Poor nurse-physician collaboration is a pivotal factor accounting for ED nurses' moral distress.

Caring for victims of child maltreatment: Pediatric nurses' moral distress and burnout

BACKGROUND

Moral distress is a significant concern for nurses as it can lead to burnout and intentions to leave the profession. Pediatric nurses encounter stressful and ethically challenging situations when they care for suspected victims of child maltreatment. Data on pediatric nurses' moral distress are limited, as most research in this field has been done in adult inpatient and intensive care units.

AIM

The purpose of this study was to describe pediatric nurses' moral distress and evaluate the impact of caring for suspected victims of child maltreatment on nurses' moral distress, burnout, and intention to leave. Design and method: This descriptive cross-sectional correlational study was conducted in a mid-Atlantic, urban area Magnet pediatric level I trauma center that cares for over 1800 cases of suspected child maltreatment annually. An anonymous electronic survey was sent to all the nurses working at the hospital.

ETHICAL CONSIDERATIONS

Institutional Review Board approval was received from the first author's university and the hospital where the study was conducted.

FINDINGS

Overall, nurses (N = 146) reported low levels of moral distress with a mean score of 59.54 (SD = 49.22) and a range of 0-300 on the Moral Distress Scale Neonatal-Pediatric version. Although the frequency of caring for suspected child maltreatment victims did not affect nurses' moral distress, caring for victims with fatal maltreatment contributed to nurses' intention to leave, χ² (1) = 5.35, p = 0.02.

CONCLUSION

The results of this study add to the understanding of moral distress in pediatric nursing. Caring for victims with fatal maltreatment impacts pediatric nurses' intention to leave.

Predictors of moral distress among nurses working in Jimma University Medical Center, South West Ethiopia

Background

Moral distress is characterized by biopsychosocial, cognitive, and behavioral effects experienced by clinicians when their values are compromised by internal or external constraints, which results in the inability to give the desired care to patients.

Objective

To assess predictors of moral distress among nurses working in Jimma University Medical Center, South West Ethiopia.

Methods

An institution-based cross-sectional study design was used. A simple random sampling technique was applied to select a total of 248 study participants. Data were collected using a structured self-administered questionnaire, which contains socio-demographic characteristics, Moral Distress Scale-Revised, personal factors, and organizational factors. The data were entered into Epidata version 3.1 and analyzed by SPSS software version 20. Descriptive statistics, bivariate analysis, and multivariable logistic regression analysis were performed. Finally, P-value <0.05 was used to declare and include variables with statistically significant in predicting the outcome variable.

Results

More than two-thirds of the study participants 170 (68.5%) were females. The mean age of the respondents is 29 years. Among the study participants, 174 (70.16%) nurses had experienced a high level of moral distress. Sex, working hours, professional commitment, autonomy, and working environment were statistically significant predictors of moral distress.

Conclusions

More than two-thirds of the nurses were experiencing a high level of moral distress. This will affect the nursing service quality, nurses, the nursing profession, and the organization as a whole. This finding is critical for the study since the problem is happening in the presence of low nurse to patient ratio and low nursing care quality. Sex, working hours per week, professional commitment, autonomy, and working environment were identified as predictors of moral distress.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units

AIM

To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting.

BACKGROUND

During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex.

SOURCES OF EVIDENCE

Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication.

DISCUSSION

The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research.

CONCLUSIONS

Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

Instruments to assess moral distress among healthcare workers: A systematic review of measurement properties

BACKGROUND

An increasing number of professionals are challenged by the evolution of modern healthcare and society, often characterized by more expectations with reduced resources. Moral distress is among the psychophysical conditions now most under investigation in order to improve the wellbeing of professionals, the sustainability of organizations and the quality of care. Over the last decades, several instruments have been developed to assess the frequency or intensity of moral distress in different studies. Yet, there has not been, so far, a systematic assessment of the qualitative properties of the various instruments measuring moral distress in healthcare workers based on a universally accepted standardized framework.

OBJECTIVE

(1) To identify all instruments for the measurement of moral distress available in recent literature; (2) to evaluate the evidence regarding their measurement properties; (3) to facilitate the selection of the most appropriate instrument to be adopted in practice and research.

DESIGN

Systematic literature review.

DATA SOURCES

PubMed, CINAHL, and PyscINFO.

REVIEW METHODS

The COnsensus-based Standards for the selection of health Measurement INstruments checklist was used to evaluate the methodological quality of the identified studies. The quality of measurement properties of each instrument was evaluated using Terwee's quality criteria.

RESULTS

Among the 1268 studies found, 88 full-text articles evaluated moral distress adopting different tools. Thirty two of them had a methodological design. The measurement instruments assessed in this review are different in terms of targeted population and items. The instruments were then divided into two main categories: (1) Corley's instruments on moral distress (Moral distress scale and Moral Distress Scale - Revised) and (2) instruments not directly derived from Corley's moral distress theory (Moral Distress thermometer, Moral Distress Risk Scale, Ethical Stress Scale or Moral Distress in Dementia Care Survey). The first set is the most frequently studied and used in different clinical settings and healthcare populations. A variety of psychometric properties have been evaluated for each instrument, revealing different qualities in the methodology used.

CONCLUSIONS

Several instruments assessing moral distress in healthcare workers have been identified and evaluated in this systematic review. Based on the criteria used here, Corley's instruments on moral distress seems to be the most useful and most appropriate to the clinical setting for practice and research purposes.

TWEETABLE ABSTRACT

The aim of this systematic review was to identify the instruments measuring moral distress now available in the literature, in order to (1) assess the evidence about their measurement properties, (2) support the selection of the most appropriate instrument to be used in practice and research.

Managing Moral Distress in the Workplace:: Creating a Resiliency Bundle

Nurse leaders within a 43-bed pediatric intensive care unit introduced a pre- and post-implementation evidence-based practice project to determine which resilience enhancing techniques were helpful among a multidisciplinary team. A statistically significant increase in post-intervention group resilience (79.9 to 83.4, p < 0.0001) was achieved within 6 months of the “resiliency bundle” implementation. Forty-seven critical care staff including registered nurses, respiratory therapists, unit secretaries, medical doctors, chaplains, child life specialists, patient care techs, and nurse practitioners self-selected resiliency bundle components and provided their feedback and resilience level pre- and post-implementation. Preferred uses of resilience enhancement techniques were analyzed by discipline, experience level, and age.

Clima ético, estrés de conciencia y laboral de enfermeras y médicos que laboran en cuidados intensivos neonatal

El objetivo del presente estudio fue determinar la relación entre la percepción del clima ético, el estrés moral y el relacionado con el trabajo. El diseño fue descriptivo correlacional y el muestreo fue tipo censo con un total de muestra de 106 participantes (80 profesionales de enfermería y 26 médicos). Los resultados mostraron que existe una relación negativa y significativa del clima ético con el estrés laboral (rs =-.326, p<.01). Además, se identificó como hallazgo adicional que el clima ético predice el estrés relacionado con el trabajo, tanto en médicos como en enfermeras (R2=7.9, p=.004). La evidencia científica del presente estudio confirma que la bioética como ciencia debe ser competencia de todos los profesionales de la salud y, en particular, de la enfermería, debido a los desafíos éticos y morales de su práctica profesional, especialmente en áreas críticas debido a las políticas, la normatividad y los recursos con los que cuentan el lugar de trabajo. Tanto el clima ético como el estrés moral y laboral deben ser considerados por las instituciones de salud, teniendo en cuenta que pueden influir negativamente en la salud de los médicos y enfermeras que brindan los cuidados, lo cual limita la calidad de la atención.

Moral distress: Developing strategies from experience

BACKGROUND

Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress.

OBJECTIVES

We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience.

RESEARCH DESIGN

An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers.

PARTICIPANTS

Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital.

RESEARCH CONTEXT

This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies.

ETHICAL CONSIDERATIONS

The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project.

FINDINGS

Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports.

DISCUSSION

Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting.

CONCLUSION

This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

Prevalence of Coping Strategy Training in Nursing School Curricula

BACKGROUND

Stress and burnout are plaguing critical care nurses across the globe and leading to high levels of turnover. Resilience-building strategies such as mindfulness, self-care, and well-being can help shield nurses from the negative effects of workplace stress. As the first line of defense, nursing schools could provide students with strategies that build resilience; however, little is known about the availability of such resources in nursing education.

OBJECTIVES

To determine the prevalence of resources and curricula targeting resilience training and stress reduction at nursing schools across the United States.

METHODS

Raters analyzed publicly available college/ university websites and course catalogs of a sample of nursing schools in the United States to determine the availability of resilience resources and curricula.

RESULTS

None of the schools surveyed regularly screened their students for burnout syndrome, and only 9% of schools had a formal curriculum that included resilience training.

CONCLUSIONS

Training in practices to build resilience and prevent burnout is essentially absent from accredited nursing schools. This highlights an important opportunity to modify existing curricula to include preventative strategies-such as developing positive coping skills- that could mitigate symptoms of workplace stress in future generations of nurses.