Multi-professional perspectives to reduce moral distress: A qualitative investigation

BACKGROUND

Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited.

RESEARCH OBJECTIVE

The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center.

PARTICIPANTS & RESEARCH CONTEXT

Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim.

RESEARCH DESIGN

Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the university and medical center institutional review boards.

FINDINGS

Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities.

CONCLUSION

Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Covid-19 Vaccine Hesitancy and Under-Vaccination among Marginalized Populations in the United States and Canada: A Scoping Review

BACKGROUND

Amid persistent disparities in Covid-19 vaccination and burgeoning research on vaccine hesitancy (VH), we conducted a scoping review to identify multilevel determinants of Covid-19 VH and under-vaccination among marginalized populations in the U.S. and Canada.

METHODS

Using the scoping review methodology developed by the Joanna Briggs Institute, we designed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020-October 25, 2022. We combine frequency analysis and narrative synthesis to describe factors influencing Covid-19 VH and under-vaccination among marginalized populations.

RESULTS

The search captured 11,374 non-duplicated records, scoped to 103 peer-reviewed articles. Among 14 marginalized populations identified, African American/Black, Latinx, LGBTQ+, American Indian/Indigenous, people with disabilities, and justice-involved people were the predominant focus. Thirty-two factors emerged as influencing Covid-19 VH, with structural racism/stigma and institutional mistrust (structural)(n = 71) most prevalent, followed by vaccine safety (vaccine-specific)(n = 62), side effects (vaccine-specific)(n = 50), trust in individual healthcare provider (social/community)(n = 38), and perceived risk of infection (individual)(n = 33). Structural factors predominated across populations, including structural racism/stigma and institutional mistrust, barriers to Covid-19 vaccine access due to limited supply/availability, distance/lack of transportation, no/low paid sick days, low internet/digital technology access, and lack of culturally- and linguistically-appropriate information.

DISCUSSION

We identified multilevel and complex drivers of Covid-19 under-vaccination among marginalized populations. Distinguishing vaccine-specific, individual, and social/community factors that may fuel decisional ambivalence, more appropriately defined as VH, from structural racism/structural stigma and systemic/institutional barriers to vaccination access may better support evidence-informed interventions to promote equity in access to vaccines and informed decision-making among marginalized populations.

Experiencing Moral Distress Within the Intimate Partner Violence & Sexual Assault Workforce

Purpose

Moral distress (MD) refers to the psychological disequilibrium that emerges when institutional policies and/or practices conflict with an individual's professional values and ethics. MD has been interrogated frequently in health care and ancillary medical settings, and has been identified as a critical barrier to enhanced organizational climate and patient care. However, little work has investigated experiences of MD among members of the intimate partner violence (IPV) and sexual violence (SV) workforce.

Methods

This study investigates MD in a sample of IPV and SV service providers via secondary analysis of 33 qualitative interviews conducted with service providers in the summer and fall of 2020 as the COVID-19 pandemic response was unfolding.

Results

Qualitative content analysis revealed multiple overlapping vectors of MD experienced by IPV and SV service providers related to institutional resource constraints, providers working beyond their capacity and/or competency, shifting responsibilities within service agencies creating burdens among staff; and breakdowns in communication. Impacts of these experiences at individual, organizational, and client levels were identified by participants.

Conculsions

The study uncovers the need for further investigation of MD as a framework within the IPV/SV field, as well as potential lessons from similar service settings which could support IPV and SV agencies in addressing staff experiences of MD.

Medical artificial intelligence ethics: A systematic review of empirical studies

Background

Artificial intelligence (AI) technologies are transforming medicine and healthcare. Scholars and practitioners have debated the philosophical, ethical, legal, and regulatory implications of medical AI, and empirical research on stakeholders' knowledge, attitude, and practices has started to emerge. This study is a systematic review of published empirical studies of medical AI ethics with the goal of mapping the main approaches, findings, and limitations of scholarship to inform future practice considerations.

Methods

We searched seven databases for published peer-reviewed empirical studies on medical AI ethics and evaluated them in terms of types of technologies studied, geographic locations, stakeholders involved, research methods used, ethical principles studied, and major findings.

Findings

Thirty-six studies were included (published 2013-2022). They typically belonged to one of the three topics: exploratory studies of stakeholder knowledge and attitude toward medical AI, theory-building studies testing hypotheses regarding factors contributing to stakeholders' acceptance of medical AI, and studies identifying and correcting bias in medical AI.

Interpretation

There is a disconnect between high-level ethical principles and guidelines developed by ethicists and empirical research on the topic and a need to embed ethicists in tandem with AI developers, clinicians, patients, and scholars of innovation and technology adoption in studying medical AI ethics.

"The hierarchy is your constraint:" a qualitative investigation of social workers' moral distress across a U.S. health system

This paper reports findings from a qualitative study on the triggers of hospital social workers' moral distress at a large southern U.S. health system. Moral distress occurs when ethical conflict cannot be resolved in a way that aligns with an individual's personal and professional values and ethics. Participants indicated that moral distress derives from both individual interactions and the culture and climate of health systems. For example, participants expressed how sources of moral distress derived from client-centered decisions, such as end-of-life care and patient autonomy; interpersonal dynamics, including team or supervisory conflict; structural issues, such as insurance barriers or internal hospital policies; and organizational values, such as perceptions of institutional support and validation. Implications of this research suggest that health systems need to foster positive ethical environments that nurture clinicians' health and mental health through programs that aim to increase moral resilience, promote empowerment, and foster wellness.

Experiences of gestational surrogacy for gay men in Canada

This paper reports on findings from a qualitative study that examined how Canada's socio-political context influenced gestational surrogacy for same-sex male couples. Semi-structured interviews were conducted with gay fathers and gestational surrogates to investigate supports and barriers of pursuing surrogacy. Questions explored publicly available information, policies and practices of fertility clinics and hospitals, post-birth resources and cultural attitudes regarding same-sex parenthood. Findings suggest that in Canada, a global leader in LGBT rights and inclusive same-sex parenting legislation, participants encountered inadequate same-sex inclusive resources and insufficient provider competencies. The aim of this study was to inform individual and institutional recommendations to counteract biases in fertility care and post-birth services. Following interview analysis, five key strategies were identified: (1) more accessible information on paths to same-sex parenthood; (2) more inclusive fertility clinic and hospital practices; (3) recognition of same-sex fatherhood in formal documentation; (4) post-birth resources such as formula feeding, play groups and first aid courses intended for same-sex parent families; and (5) shifts in cultural attitudes of same-sex parenthood and, specifically, gay fatherhood. Approaches that subvert heteronormative discourses embedded in fertility and reproduction are required to legitimise and support same-sex parent families.

#socialwork: An International Study Examining Social Workers’ Use of Information and Communication Technology

Information and Communication Technologies (ICTs) permeated social work practice before coronavirus disease 2019 (COVID-19). In addition to ICT-based formal services (e.g. e-counselling), social workers used ICTs informally as an adjunct to face-to-face practice. Building on our previous research, our cross-sectional online survey examined social workers’ informal use of ICTs in four countries: Canada, the USA, Israel and the UK. The survey was administered through Qualtrics software among social workers across Canada (n = 2,609), the USA (n = 1,225), Israel (n = 386) and the UK (n = 134), and analysed using IBM SPSS Statistics version 26. The findings substantiate the ubiquitous use of informal ICTs in social work practice, as an adjunct to face-to-face treatment, across the four countries. Given the current, unprecedented context of COVID-19, we discuss the meaning of our findings related to access, ethical considerations (e.g. professional boundaries) and supervision in the context of restricted face-to-face practice. We discuss the implications for social work practice, education and research, and conclude that in the COVID-19 context, there is an even greater need for research, clinical discussion, supervision and policy on informal ICT use in social work practice.

Promoting a positive school climate for sexual and gender minority youth through a systems approach: A theory-informed qualitative study

Pervasive bias-based bullying of sexual and gender minority youth amid often hostile school climates signals the importance of systems approaches to effect change. Nevertheless, most research on bullying victimization tends to adopt either lesbian, gay, bisexual, and transgender (LGBT)-specific approaches or broader approaches that omit mention of LGBT youth. We conducted a qualitative study, with the systems view of school climate as an organizing analytical framework, to explore determinants of school climate for LGBT youth and strategies for intervention. In-depth, semistructured interviews with 16 key informants, including teachers, school staff, administrators, frontline community providers, and experts on bullying victimization of LGBT youth, illustrate reciprocal and multilevel factors that produce school climates, which in turn foster or prevent bullying of LGBT youth. Not only do distal factors (e.g., LGBT-affirmative legislation, targeted resource allocation for LGBT programming) impact school microsystems, but proximal factors in the microsystem, including enacted homophobia and transphobia through multilateral interpersonal interactions, also influence meso- and macrolevel phenomena, such as the values and mission of the school. Participants recommended multilateral interventions and training that address both proximal and distal contexts of school social ecologies, including teacher-student, peer-to-peer (e.g., gay-straight alliances), and teacher-administrator interactions; behavioral health professional roles and responsibilities; school curricula and libraries; school-board engagement with individual schools; LGBT-inclusive policies; targeted resource allocation; and systemwide accountability. Positive school climates for LGBT youth are promoted through multilevel and reciprocal interventions that support social, psychological, and physical safety not just for LGBT students but for all students. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

What the HEC-C? An Analysis of the Healthcare Ethics Consultant-Certified Program: One Year in

Efforts to professionalize the field of bioethics have led to the development of the Healthcare Ethics Consultant-Certified (HEC-C) Program intended to credential practicing healthcare ethics consultants (HCECs). Our team of professional ethicists participated in the inaugural process to support the professionalization efforts and inform our views on the value of this credential from the perspective of ethics consultants. In this paper, we explore the history that has led to this certification process, and evaluate the ability of the HEC-C Program to meet the goals it has set forth for HCECs. We describe the benefits and weaknesses of the program and offer constructive feedback on how the process might be strengthened, as well as share our team's experience in preparing for the exam.

A Process-Based Approach to Responding to Parents or Guardians Who Hope for a Miracle

When parents or guardians hope for a miracle for their child who is critically ill, ethical and professional challenges can arise. Often, although not always, the parent or guardian's hope for a miracle entails a request for continued life-sustaining interventions. Striking a balance between the pediatrician's conception of good medicine and the parent or guardian's authority requires a response that is sensitive, practical, and ethically sound. In this article, we recommend 3 cumulative steps that promote such a response. First, we recommend ways of exploring essential issues through open inquiry, interdisciplinary dialogue, and self-reflection. As part of this exploration, pediatricians will discover that parents or guardians often have unique ideas about what a miracle might be for their child. The second step includes analyzing this diversity and seeking understanding. We classify the hope for a miracle into 3 distinct categories: integrated, seeking, and adaptive. After the pediatrician has categorized the parent or guardian's hope, they can consider specific recommendations. We detail context-specific responses for each kind of hope. By attending to these nuances, not only will the parent or guardian's perspective be heard but also the pediatrician's recommendation can strike a balance between advocating for their conception of good medicine and respecting the parent or guardian's beliefs.

The emergence of ethical issues in the provision of online sexual health outreach for gay, bisexual, two-spirit and other men who have sex with men: perspectives of online outreach workers

BACKGROUND

Mobile applications and socio-sexual networking websites are used by outreach workers to respond synchronously to questions and provide information, resources, and referrals on sexual health and STI/HIV prevention, testing, and care to gay, bisexual and other men who have sex with men (GB2M). This exploratory study examined ethical issues identified by online outreach workers who conduct online sexual health outreach for GB2M.

METHODS

Semi-structured individual interviews were conducted between November 2013 and April 2014 with online providers and managers (n = 22) to explore the benefits, challenges, and ethical implications of delivering online outreach services in Ontario, Canada. Interviews were digitally recorded and transcribed verbatim. Thematic analyses were conducted, and member-checking, analyses by multiple coders, and peer debriefing supported validity and reliability.

RESULTS

Four themes emerged on the ethical queries of providing online sexual health outreach for GB2M: (a) managing personal and professional boundaries with clients; (b) disclosing personal or identifiable information to clients; (c) maintaining client confidentiality and anonymity; and (d) security and data storage measures of online information. Participants illustrated familiarity with potential ethical challenges, and discussed ways in which they seek to mitigate and prevent ethical conflict.

CONCLUSIONS

Implications of this analysis for outreach workers, researchers, bioethicists, and policy-makers are to: (1) understand ethical complexities associated with online HIV prevention and outreach for GB2M; (2) foster dialogue to recognize and address potential ethical conflict; and (3) identify competencies and skills to mitigate risk and promote responsive and accessible online HIV outreach.

“Pray That God Will Change You”: The Religious Social Ecology of Bias-Based Bullying Targeting Sexual and Gender Minority Youth—A Qualitative Study of Service Providers and Educators

The bullying of sexual and gender minority youth (SGMY) is pervasive, with documented negative impacts on health. We explored the social ecology of bullying of SGMY, with a focus on religion as a source or context of bullying. Semistructured interviews with service providers, educators, and administrators in Toronto, Canada, who work with SGMY explored perspectives on the bullying of SGMY, focusing on religiously based bullying and strategies for intervention. Interviews (45-60 minutes) were recorded, transcribed, and analyzed using thematic content analysis. The data revealed religiously based homophobic discourse that permeates religious (places of worship, faith-based schools) and secular microsystems (public schools, families) across SGMY’s social ecology. The language and ideology of “sin” and “conversion” were evidenced in direct religiously based bullying of SGMY in schools, and victimization in places of worship and family microsystems, as well as serving as a rationale for bullying and nonintervention by teachers, school staff, administrators, and family members. Multisectoral and multilevel influences of religiously based sexual prejudice on the bullying of SGMY suggest that existing individual-level and microsystem-level responses in schools should be augmented with institutional, policy, and legal interventions in SGMY’s more distal social ecology in order to effectively prevent religiously based homophobic bullying.

Do children with gender dysphoria have intense/obsessional interests?

This study examined whether children clinically referred for gender dysphoria (GD) show increased symptoms of autism spectrum disorder (ASD). Circumscribed preoccupations or intense interests were considered as overlapping symptoms expressed in GD and ASD. In gender-referred children (n = 534; 82.2% male) and their siblings (n = 419; 57.5% male), we examined Items 9 and 66 on the Child Behavior Checklist, which measure obsessions and compulsions, respectively. Non-GD clinic-referred (n = 1,201; 48.5% male) and nonreferred (n = 1,201; 48.5% male) children were also examined. Gender-referred children were elevated compared to all other groups for Item 9, and compared to siblings and nonreferred children for Item 66. A gender-related theme was significantly more common for gender-referred boys than male siblings on Item 9 only. A gender-related theme was not significantly more common for gender-referred girls compared to their female siblings on either item. The findings for Item 9 support the idea that children with GD show an elevation in obsessional interests. For gender-referred boys in particular, gender-related themes constituted more than half of the examples provided by their mothers. Intense/obsessional interests in children with GD may be one of the factors underlying the purported link between GD and ASD.