Moral injury has primarily been studied from a clinical perspective to assess, diagnose and treat the outcomes of morally injurious experiences in healthcare and military settings. Little is known about the lived experiences of those who have had their moral values transgressed in business settings. Public scandals such as Enron suggest that moral injury may also occur in for-profit business settings. In this qualitative study, we examine the lived experiences of 16 employees in for-profit business organisations who identified as having (...) suffered moral injury. Using semi-structured narrative interviews, our findings offer insights into the values that employees feel are transgressed and the pathways between morally injurious experiences and the long-term outcomes. Based on our findings, we propose a conceptual pathway to moral injury, which suggests that experiencing moral transgressions has a profound impact on employees as they feel a threat to their “good-me” identity, however, employees employ various coping strategies to minimise the impact during the event. Employees exited the organisation and often changed career paths to protect themselves from further injury and to make up for moral failure. This study advances our understanding of the experience of moral injury in business settings and the pathway explaining how and why people react differently to moral transgressions. (shrink)

Since the 1960s, it has been recognized that “medical ethics,” the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary (...) aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one’s prior profession’s nomenclature as a prefix to “ethicist,” under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good. (shrink)

Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out of this research must (...) justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician’s conscience, or that the trial will impose excessive burdens on the clinician. (shrink)

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals’ moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts (...) in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change. (shrink)

Background The global pandemic raised ethical issues for nurses about caring for all patients, not just those with COVID-19. Italy was the first European country to be seriously affected by the first wave, while Estonia’s infection and death rates were among the lowest in Europe. Did this raise different ethical issues for nurses in these two countries as well? Aim The aim was to describe and compare ethical issues between nurses working during the first wave of the COVID-19 pandemic in (...) Estonia and Italy. Research design A cross-sectional survey study with a self-administered questionnaire. The impact of COVID- 19 emergency on nursing care questionnaire was used. Participants and research context Convenience sampling was used to recruit 1098 nurses working during the first wave of the pandemic in 2020: 162 from Estonia and 936 from Italy. Ethical considerations Research ethics approvals were obtained, and the nurses provided informed consent. Results The most frequent ethical issues for Estonian nurses were professional communication and ensuring access to care for patients without COVID-19, and for Italian nurses, the end-of-life care and the risk of them getting the virus and transmitting it to their loved ones. There were no statistically significant differences in the frequency of ethical issues between Estonian nurses working with patients with and without COVID-19. Italian nurses caring for COVID-19 patients faced statistically significantly more (both p <.001) issues around prioritising patients and end-of-life. Nurses working with patients without COVID-19 in Italy faced more issues about access to care ( p <.001). Conclusions Estonian and Italian nurses, working in different clinical contexts during the first wave of the pandemic, faced different ethical issues. Local contextual aspects need to be considered to support nurses’ ethical decision-making in providing care during future crises and to ensure ethical care for patients. (shrink)

South African research ethics committees (RECs) faced significant challenges during the COVID-19 pandemic. Research ethics committees needed to find a balance between careful consideration of scientific validity and ethical merit of protocols, and review with the urgency normally associated with public health emergency research. We aimed to explore the views of South African RECs on their pandemic preparedness and response during COVID-19. We conducted in-depth interviews with 21 participants from RECs that were actively involved in the review of COVID-19 related (...) research, at seven academic institutions across South Africa. Interviews were conducted remotely using an in-depth interview guide that included questions regarding REC preparedness and response to COVID-19. Interviews were conducted until data saturation, and audio-recordings were transcribed verbatim and coded. An inductive approach to thematic analysis was used to organise data into themes and sub-themes. This study focused on three main themes: coping during COVID-19, building REC capacity during pandemic times and a consistently cautious approach to mutual recognition of REC reviews. Despite an initial sense of unpreparedness, RECs were able to adapt and maintain careful ethical oversight of both COVID and non-COVID research, and the rigour of REC reviews. Several important lessons for preparedness and response to future pandemics were identified, including heightened awareness of publication, funding and political pressures, the importance of regular training for RECs and researchers, and strategies to enhance moral resilience of REC members. Incremental steps are needed to build trust and authentic partnerships among RECs in inter-pandemic times, to facilitate collaboration during future public health emergencies. (shrink)

Background: Compassion fatigue and professional quality of life are important in health and professional ethics. Aim: This study aimed to determine the relationship between compassion satisfaction, compassion fatigue, secondary traumatic stress, and moral injury in nurses. Research design: This research is a cross-sectional descriptive-analytical study. The research community of this research was all the nurses of the teaching hospitals of Ardabil city. Three questionnaires on demographic characteristics, the Professional Quality of Life Scale (ProQOL), and the Moral Injury Events Scale were (...) used to collect data. SPSS (version 22) software was used for data analysis. Participants and research context: The study recruited 297 nurses randomly selected from five teaching hospitals in Ardabil city. Ethical considerations: Ethical approval was obtained from the Ardabil University of Medical Sciences ethics committee (with the code of ethics IR.ARUMS.REC.1401.198). Informed consent was obtained from the participants. Results: The results showed that the mean compassion satisfaction score of this study’s participants was 37.61 ± 8.86, the mean compassion fatigue score of this study’s participants was 28.73 ± 7.04, and the mean secondary traumatic stress score of this study’s participants was 29.95 ± 7.84. The mean score of moral injury among nurses was 31.19 ± 8.54. The results showed a negative significant relationship between compassion satisfaction and moral injury ( p < 0.001). Also, there is a positive significant relationship between compassion fatigue and secondary traumatic stress with moral injury ( p < 0.001). Conclusion: The results of this study show a negative relationship between compassion satisfaction and moral injury. According to the results of the present study, nurse managers should implement educational interventions, create ethical processes, and clear ethical guidelines to reduce moral injury and increase compassion satisfaction. (shrink)

This paper explores the phenomenon of vulnerabilisation in relation to the experiences of persons with chronic illnesses. We distinguish a range of kinds of vulnerability, including epistemic vulnerabilities related to epistemic injustices, and describe various interpersonal and institutional processes which can create, exacerbate, and intensify those vulnerabilities. The dynamics of vulnerablisation are related to individual vices and institutional failings, the the pervasive pathophobia of many societies, and various contingent life-events. We conclude that susceptibility to varieties of vulnerabilisation is ultimately reflective (...) of the fragility that is definitive of the human condition. (shrink)

Background eHealth was widely used during the COVID-19 pandemic. Much attention was given to the technical aspects of eHealth, such as infrastructure and cost, while the soft skill of compassion remained underexplored. The wide belief in compassionate care is more compatible with in-person interactions but difficult to deliver via e-platforms where personal and environmental clues were lacking urges studying this topic. Purpose to explore the experience of delivering compassionate care via an eHealth platform among healthcare professionals working to contain the (...) COVID-19 pandemic. Methods A qualitative study design with an interpretative phenomenological analysis approach was used. Twenty healthcare professionals (fifteen nurses and five physicians) who provided care using technology platforms, such as telephone hotlines, mobile apps, and social media, were interviewed individually. Ethical considerations Permission to conduct the study was obtained from the Institutional Review Board. Results Participants stated that “eHealth enabled compassionate care during the pandemic” by ensuring patient care availability and accessibility. They shared experiences of “communicating compassionate care via eHealth” with suggestions of addressing patients’ needs with empathy, adopting a structured protocol to guide eHealth communication, and using more advanced visual-media methods to promote human-to-human interaction. They recommended “setting realistic mutual expectations” considering the limitations of eHealth in handling complex health situations and staffing shortages. Participants considered “low eHealth literacy hinders compassion.” Additionally, they recommended the need for “institutional/system-level support to foster compassionate care.” Conclusion Participants recognized the importance of integrating compassion into eHealth services. Promotion of compassionate care requires standardization of eHealth services with institutional and system-level support. This also includes preparing adequate staffing who can communicate compassionate care via eHealth, set realistic expectation, and adjust communication to eHealth literacy level while meeting the needs of their patients. (shrink)

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. (shrink)

COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to (...) include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum—physicians, scientists, and the community-at-large including the pharmaceutical industry—need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks. (shrink)

Introduction: Moral injury involves the adverse psychological, biological, spiritual, behavioural, and social consequences of actions that violate moral values. It can lead to anxiety, depression, burnout, and post-traumatic stress disorder. Nurses, who often face ethical dilemmas, are particularly vulnerable. Despite its significance, the relationship between moral injury and mental health outcomes in nurses remains underexplored. Aim: This systematic review aimed to describe the associations among moral injury, anxiety, depression, and quality of life in nurses. Methods: The review was registered in (...) PROSPERO (CRD42023438731) and was conducted following the PRISMA guidelines. A literature search was performed in December 2023 across PubMed, CINAHL, Scopus, and Web of Science. Peer-reviewed primary research involving nurses, published in English or Italian, without time restrictions, was considered eligible. The risk of bias and the quality of evidence were assessed using the Joanna Briggs Institute checklist and the GRADE approach. Results: Out of 4730 articles identified, eight met the inclusion criteria. The analysis revealed significant positive associations between moral injury, anxiety, and depression, along with a significant negative association with quality of life. Conclusion: These findings highlight the need for healthcare systems to implement strategies that mitigate moral injury among nurses. Future research should prioritize longitudinal studies to explore causal relationships and develop targeted interventions. Additionally, standardizing the concept and measurements of moral injury is crucial for enhancing the comparability and understanding of this phenomenon. (shrink)

The glaring lack of formal and informal caregivers in Germany has not only become apparent in hospitals and nursing homes but also in home care arrangements. One tension is particularly pertinent in such arrangements: a ‘family-oriented’ logic of the long-term care insurance and the individual wishes of those in need of care meet the actual possibilities of family carers. This care gap has been compensated for by 24-hour care workers, so-called ‘live-ins’, from Eastern Europe for some years. This contribution maps (...) the ‘live-ins’ situation comprehensively from an ethical perspective. Based on different constellations regarding the ‘live-ins’ status as a professional nurse or non-professional caregiver, which ethical principles and moral norms are affected by whom and potentially conflict with each other in such home care arrangements at a micro and meso level of care are outlined. Special attention is paid to the tension between self-care and care for others, and to questions of the shared responsibility in and social responsibility of those external services that are involved in home care in addition to the ‘live-in’. In order to uncover, understand and influence the current ethical problems, an ethical framework that considers both the divergent interests of all individuals involved in the home care arrangement and their mutual dependency and vulnerability is needed. (shrink)

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising (...) from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience. (shrink)

Background: Moral courage is defined as the courage to act in ethical conflicts based on individual or professional values despite the personal risks involved. Nurses justify their decisions to act morally courageously as part of their ethical decision-making. Objective: To describe registered nurses’ justifications for acting morally courageously, or not, in ethical conflicts where they needed moral courage. Research design: A narrative inquiry with a holistic content approach was used. Individual, in-depth interviews were conducted in January–February 2023. The data were (...) analysed using holistic content analysis. Participants and research context: Fourteen registered nurses with experience in situations where they needed moral courage participated. The nurses came from the somatic, palliative, mental health, and substance abuse care fields in Finland. Ethical considerations: Good scientific practice was followed. Ethical approval was obtained before data collection from the university’s ethics committee. Findings: The nurses needed moral courage in ethical conflicts with patients present and between professionals. Individual responsibility, professional ethics, and emotions were identified as bases of nurses’ justifications for morally courageous acts. The justifications for acting morally courageously, or not, had individual, contextual, and organisational perspectives. Morally courageous acts included starting a discussion about the conflict with other professionals and reporting the situation in writing within one’s organisation. Discussion and conclusions: The identified bases and perspectives of justifications illustrate the complexity of nurses’ decision-making in ethical conflicts, either leading to morally courageous acts or not. These results can inform nursing practice and research in developing processes to strengthen nurses’ moral courage and examining relationships between moral courage and other concepts, such as moral resilience. (shrink)

Mr. Rivers’ case offers an example of how a caregiver may perceive the concept of moral distress. The nurse is experiencing what is described as moral distress at the prospect of participating in C...