The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic’s trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach (...) to develop a moral distress intervention—proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness. (shrink)

Background Moral distress is a complex and challenging issue in the nursing profession that can negatively affect the nurses’ job satisfaction and retention and the quality of patient care. This study focused on describing the resources and constraints, consequences, and interventions of moral distress in nurses. Methods In a literature review, an extensive electronic search was conducted in databases including PubMed, ISI, Scopus as well as Google Scholar search engine using the keywords including “moral distress” and “nurses” to identify resources, (...) constraints, consequences, and interventions about moral distress in nurses, from the earliest records up to 26 December 2020. The required data were extracted from 61 relevant studies by two independent reviewers. Results Resources and constraints in the occurrence of moral distress among nurses can be divided into three general categories including internal factors, clinical factors, and external factors. The consequences of moral distress on nurses and the medical system reduced moral sensitivity, development of psychological and physical health problems, and the intention to leave the profession. The potential effective interventions were the implementation of integrated communication programs, strengthening physician–nurse collaboration, nursing involvement in clinical decision-making and end-of-life issues, social support, using a resiliency bundle, interdisciplinary discussion, and promoting nurses’ ethical and communication skills. Conclusion There are a wide range of resources and constraints impacting moral distress in nurses that could lead to negative consequences. Further studies are necessary to identify, evaluate, and implement a range of potential effective interventions for the management of moral distress in nurses. (shrink)

An ethics reflection group is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of (...) 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services. (shrink)

Background: Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students. Aim: To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing. Research design: A descriptive qualitative design was employed to explore the community health nursing experiences of the nursing students (...) that led them to have moral distress. Participants and research context: The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year. Ethical considerations: Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. Findings: Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community. Conclusion: This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the “real world,” where the ideals they have will be constantly challenged and tested. (shrink)

Background: Experiencing moral distress is traumatic for nurses. Ignoring moral distress can lead to job dissatisfaction, improper handling in the care of patients, or even leaving the job. Thus, it is crucial to use valid and reliable instruments to measure moral distress. Objective: The purpose of this study was to determine the reliability and the validity of the Persian version of the Moral Distress Scale–Revised among a sample of Iranian nurses. Research design: In this methodological study, 310 nurses were recruited (...) from all hospitals affiliated with the Qazvin University of Medical Sciences from February 2014 to April 2015. Data were collected using a demographic questionnaire and the Moral Distress Scale–Revised. The construct validity of the Moral Distress Scale–Revised was evaluated using principal component analysis and confirmatory factor analysis. Internal consistency reliability was assessed with Cronbach’s alpha. Ethical considerations: This study was approved by the Regional Committee of Medical Research Ethics. The ethical principles of voluntary participation, anonymity, and confidentiality were considered. Findings: The construct validity of the scale showed four factors with eigenvalues greater than one. The model had a good fit ( χ2(162) = 307.561, χ2/ df = 1.899, goodness-of-fit index =.904, comparative fit index =.927, incremental fit index =.929, and root mean square error of approximation (90% confidence interval) =.049 (.040–.057)) with all factor loadings greater than.5 and statistically significant. Cronbach’s alpha coefficients were.853,.686,.685, and.711for the four factors. Moreover, the model structure was invariant across different income groups. Discussion and conclusion: The Persian version of the Moral Distress Scale–Revised demonstrated suitable validity and reliability among nurses. The factor analysis also revealed that the Moral Distress Scale–Revised has a multidimensional structure. Regarding the proper psychometric characteristics, the validated scale can be used to further research about moral distress in this population. (shrink)

Background: There is growing awareness that patient care suffers when nurses are not respected. Therefore, to improve outcomes for patients, it is crucial that nurses operate in a moral work environment that involves both recognition respect, a form of respect that ought to be accorded to every single person, and appraisal respect, a recognition of the relative and contingent value of respect modulated by the relationships of the healthcare professionals in a determined context. Research question/aim: The purpose of this study (...) was to develop better understandings of perceptions of nursing’s professional respect in community and hospital settings in England. Research design: The research design was qualitative. Focus groups were chosen as the most appropriate method for eliciting discussion about nursing’s professional respect. Participants and research context: A total of 62 nurses who had been qualified for at least a year and were working in two localities in England participated in this study. Methods: Data were collected using 11 focus group sessions. The data were analysed by means of an inductive content analysis, extracting meaning units from the information retrieved and classifying the arising phenomena into conceptually meaningful categories and themes. Ethical considerations: To conduct the research, permission was obtained from the selected universities. Results: Recognition respect of human beings was perceived as ingrained in the innermost part of nurses. Regarding appraisal respect, a great importance was placed on: the interactions among healthcare professionals, the time to build trust in these relationships, the influences of the workplace characteristics and nurses’ professional autonomy and decision-making. Conclusion: Recognition respect of persons was embedded in the inmost part of nurses as individuals. Concerning appraisal respect, it was thought to be deeply enshrined in the inter- and intra-healthcare professional interactions. The forging of trusting relationships over time was deemed to be strongly associated with good quality interactions with other healthcare professionals. (shrink)

Background: Moral distress has been described as a major problem for the nursing profession, and in recent years, a considerable amount of research has been undertaken to examine its causes and effects. However, few research projects have been performed that examined the moral distress of an entire nation’s nurses, as this particular study does. Aim/objective: The purpose of this study was to determine the frequency and intensity of moral distress experienced by registered nurses in New Zealand. Research design: The research (...) involved the use of a mainly quantitative approach supported by a slightly modified version of a survey based on the Moral Distress Scale–Revised. Participants and research context: In total, 1500 questionnaires were sent out at random to nurses working in general areas around New Zealand and 412 were returned, giving an adequate response rate of 27%. Ethical considerations: The project was evaluated and judged to be low risk and recorded as such on 22 February 2011 via the auspices of the Massey University Human Ethics Committee. Findings: Results indicate that the most frequent situations to cause nursing distress were (a) having to provide less than optimal care due to management decisions, (b) seeing patient care suffer due to lack of provider continuity and (c) working with others who are less than competent. The most distressing experiences resulted from (a) working with others who are unsafe or incompetent, (b) witnessing diminished care due to poor communication and (c) watching patients suffer due to a lack of provider continuity. Of the respondents, 48% reported having considered leaving their position due to the moral distress. Conclusion: The results imply that moral distress in nursing remains a highly significant and pertinent issue that requires greater consideration by health service managers, policymakers and nurse educators. (shrink)

Moral distress is a common phenomenon among nurses and is related to the complicated work environments and complex nature of ethical situations in day-to-day nursing practice. Moral distress impacts nurses as well as patient care and the health care system. Few strategies have been identified for instructors to effectively engage with learners when communicating about moral distress. We discuss two key curricular and pedagogical strategies that should be utilized when learning about moral distress: difficult knowledge’ and ‘terror management theory’. Whether (...) it is with new nursing students or experienced nurses, there is necessary learning that needs to occur on moral distress. Difficult knowledge’ and ‘terror management theory’, when implemented, can provide a starting point for both the learner and the instructor to discuss the emotionally difficult and complex topic of moral distress. Knowledge about moral distress has the potential to mitigate its negative effects, therefore it is vital to consider educational strategies to teach nurses about this complex phenomenon. (shrink)

Background: Moral distress has various adverse effects on nurses working in critical care. Differences in personal values, and between values and self-perception of behaviour are factors that may cause moral distress. Research aims: The aims of this study were (1) to identify ethical values and self-perception of behaviour of critical care nurses in Japan and (2) to determine the items with a large difference between value and behaviour and the items with a large difference in value from others. Research design: (...) A nationwide, cross-sectional study was conducted. Participants and research context: We developed a self-administered questionnaire with 28 items, which was completed by 1014 critical care nurses in Japan. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The size of the difference in value from the others was judged by the standard deviation of each item. Ethical considerations: The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214, M2019-045). Results: The items with a large difference between value and behaviour sources were related to the working environment and decision-making support. The items with a large difference in value from others were related to hospital management and disclosure of information to patients. Discussion: Improving the working environment for nurses is important for reducing moral distress. Nurses are faced with a variety of choices, including advocating for patients and protecting the fair distribution of medical resources, and each nurse’s priorities might diverge from those of other team members, which can lead to conflict within the team. Conclusion: This study revealed items with particularly high risks of moral distress for nurses. The results provide foundational information that can guide the development of strategies to mitigate moral distress. (shrink)

BackgroundAn ethics reflection group is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark.MethodsThis is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis (...) of significance.ResultsA recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG.ConclusionThis study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives. (shrink)

Translating the social justice ideals of social work into practice can pose significant challenges for new social work graduates in contemporary contexts that are characterised by rationalism, individualism and control. This paper contributes to the debate on the place of activism in social work education by addressing the question of how social work education prepares students to manage ‘moral distress’ [Weinberg, M. 2009. "Moral Distress: A Missing but Relevant Concept for Ethics in Social Work." Canadian Social Work Review 26 : (...) 139-151; Fine, M., and E. Teram. 2013. "Overt and Covert Ways of Responding to Moral Injustices in Social Work Practice: Heroes and Mild-Mannered Social Work Bipeds." British Journal of Social Work 43. doi:10.1093/bjsw/bcs056 ] and respond to social injustices that they may encounter in their work with individuals, families and communities. Drawing on our experiences as social work educators at an Australian and an Irish university, we examine how beginning practitioners negotiate the challenges, risks and moral dilemmas of social change practices across different organisational and policy contexts. We discuss three reoccurring themes as important for students as emerging practitioners: recognising risks, acknowledging moral ‘dissonance’ in a critically reflexive manner and understanding that all social work takes place in a policy context and therefore engaging with policy is a fundamental element of practice. Our analysis concludes that ideas and expositions of activism based on nuanced, flexible and opportunistic social change practices offer significant but realistic possibilities for engaged social work practice. (shrink)

Background Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care. Aim The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care. Research (...) design The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data. Participants and research context The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities. Ethical considerations The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research. Findings Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection. Conclusion Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses’ understanding of the tool’s purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work. (shrink)

Die Anforderungen an das ethisch-professionelle Handeln Pflegender und somit auch die Forderungen an die professionelle Ethikkompetenz Pflegender im praktischen Berufsfeld wandeln sich sowohl qualitativ als auch quantitativ. Dies wird auch in den veränderten normativen Rahmungen der Pflegebildung deutlich. Der Lernort Praxis als ein zentraler Ort pflegebezogener (Aus‑)Bildungsprozesse rückt somit nochmals stärker in den Fokus der Ethikkompetenzentwicklung professionell Pflegender. Der Beitrag konturiert zentrale Anforderungen und veränderte Bezüglichkeiten für die Ethikbildung im beruflichen Handlungsfeld professioneller Pflege und formuliert davon ausgehend zentrale Prämissen an (...) organisationsethische Rahmenbedingungen mit dem Ziel, eine ethisch fundierte professionelle pflegerische Handlungspraxis zu unterstützen. (shrink)

Die Anforderungen an das ethisch-professionelle Handeln Pflegender und somit auch die Forderungen an die professionelle Ethikkompetenz Pflegender im praktischen Berufsfeld wandeln sich sowohl qualitativ als auch quantitativ. Dies wird auch in den veränderten normativen Rahmungen der Pflegebildung deutlich. Der Lernort Praxis als ein zentraler Ort pflegebezogener Bildungsprozesse rückt somit nochmals stärker in den Fokus der Ethikkompetenzentwicklung professionell Pflegender. Der Beitrag konturiert zentrale Anforderungen und veränderte Bezüglichkeiten für die Ethikbildung im beruflichen Handlungsfeld professioneller Pflege und formuliert davon ausgehend zentrale Prämissen an (...) organisationsethische Rahmenbedingungen mit dem Ziel, eine ethisch fundierte professionelle pflegerische Handlungspraxis zu unterstützen. (shrink)

An important role for all health care professionals is to be an advocate for their patients, and there is no question that many patients need advocacy to reach their health care goals. The role of advocate takes many forms, but one is to speak up when one is concerned for the safety or well‐being of a patient. A nurse is often the member of a health care team most likely to notice changes that might signal problems or poor responses to (...) treatment. The duty of the nurse is to speak up in a timely and urgent manner when the nurse believes—or fears—that the patient's safety may be at risk. Yet the role of nurses as advocates for their patients has assumed near‐mythic status. Rather than seeing advocate as one among many equally important and interrelated professional roles, the nurse, when asked, “Who are you?” is likely to give the heartfelt and passionate answer, “The patient's advocate!” This essay examines and critically analyzes the advocacy role adopted by the nursing profession and outlines the challenges it has created to nursing's contributions to collaborative practice, ethics, and policy in health care. (shrink)

Background Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. Methods We (...) explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. Results We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. Conclusion Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout. (shrink)

This study explored the influence of healthcare ageism on nurses’ moral distress. Episodic interviews were conducted on 25 Romanian nurses in 2020. Thematic analysis revealed that all moral distress sources reported reflected macro-, meso- and micro-level ageism, benevolent and hostile, self- or other-directed, including stereotyping, prejudice, and discrimination of older patients. The COVID-19 pandemic-related ageist measures increased healthcare ageism and transformed nurses’ representations of older patients accordingly. Nurses felt moral conflict both when passively witnessing ageist acts and when perpetrating them (...) to adhere to group norms, highlighting the need to combat ageism for both patients’ and nurses’ well-being. (shrink)

During the COVID-19 pandemic, nurses experienced tremendous dilemmas including the need to perform their duties in caring for patients while they have concerns about contracting the disease. This study described the moral distress of nurses in-charge of handling COVID-19 patients which can be used as baseline data for intervention programs in overcoming moral distress among nurses. This descriptive, cross-sectional study was conducted with nurses in-charge of handling COVID-19 treatment rooms. Before conducting the survey, ethical approval was obtained from the Medical (...) Faculty of Universitas Hasanuddin. Questionnaires on moral distress for clinical nurses and the demographic data questionnaire were distributed to 128 respondents. These nurses experienced relatively low levels of moral distress despite the fact that they were generally exposed to morally stressful situations. Education background appeared as a factor influencing this condition, in which higher moral distress was mostly experienced by nurses with undergraduate education. (shrink)

The term ‘moral resilience’ has been gaining momentum in the nursing ethics literature. This may be due to it representing a potential response to moral problems such as moral distress. Moral resilience has been conceptualised as a factor that inhibits immoral actions, as a favourable outcome and as an ability to bounce back after a morally distressing situation. In this article, the philosophical analysis of moral resilience is developed by challenging these conceptualisations and highlighting the risks of such limiting perspectives. (...) It is argued that moral resilience is best understood as a virtue with two associated vices, faintheartedness and rigidity. The intellectual virtue of practical wisdom is required to express resilience as a virtue. This understanding leads to recommendations for professional education, for practice and for further research. (shrink)

Objective:The purpose of this study was to describe the current situation of moral distress and to explore its influencing factors among Chinese nurses.Methods:This is an exploratory, descriptive design study. A total of 465 clinical nurses from different departments in three Grade-III, Level-A hospitals in Jinan, Shandong Province, completed the questionnaires, including demographics questionnaire, Chinese version of Moral Distress Scale–Revised, and Job Diagnostic Survey.Ethical considerations:The study was approved by the university ethics board and the local health service director.Results:The total score of (...) Moral Distress Scale–Revised was 36.01 ± 24.02 points. The mean frequency and intensity scores of moral distress were 1.13 ± 0.49 and 1.09 ± 0.58, respectively. The level of moral distress among Chinese clinical nurses was low, and the frequency and intensity of moral distress were on low to moderate level. The level of moral distress experienced by clinical nurses is associated with demographics features and job characteristics, including age, education degree, department, task significance, autonomy, and dealing with others.Conclusion:Our conclusion suggests that hospital and organizational administrations should attach much importance to the moral distress experienced by clinical nurses in China. Further studies should focus on interventions about how to reduce the levels of the frequency and intensity of moral distress among clinical nurses. (shrink)

Background:Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress suffered by (...) nurses nor a study conducted on the issue.Aim/objective:The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level.Method:The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale–Revised.Ethical considerations:The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.Results:In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.Conclusion:Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care. (shrink)

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature – and subsequently the health care ethics lexicon – in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral (...) constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques – critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of ‘constraint’ and ‘agency’. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach. (shrink)

Background: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. Discussion: Some researchers suggest that a closer examination of how socio-political structures influence healthcare (...) delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. Conclusion: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by—and influence—the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions. (shrink)

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. (shrink)

BackgroundMoral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes.MethodsA regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level (...) of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice.ResultsThe mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9).ConclusionsFemale, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals. (shrink)

BackgroundMoral dilemmas have arisen concerning whether physicians and other providers should treat patients who have declined COVID vaccination and are now sick with this disease. Several ethicists have argued that clinicians have obligations to treat such patients, yet providing care to these patients has distressed clinicians, who have at times declined to do so. Critical questions thus emerge regarding how best to proceed.Main bodyProviders face moral tensions: whether to place the benefits to an unvaccinated patient over their duties to protect (...) themselves and their families, staff and other patients, and goals of working collaboratively with patients. Clinicians’ duties to treat such patients arguably outweigh claims otherwise, but these obligations are creating moral conflict and distress for providers. Moral distress has been associated with burnout, post-traumatic stress disorder, and interpersonal and work difficulties. Given ongoing vaccine refusals, these problems are unlikely to disappear in the foreseeable future. Society has obligations to address this moral distress due to principles of reciprocity, and implicit social contracts, as part of which physicians risk their lives in caring for patients for the good of society as a whole. Responses are thus urgently needed at several levels: by hospitals, medical schools, professional societies, governments, media, providers and patients. Medical training on professionalism should address these stresses, probing why doctors have duties to treat these patients, but also how moral conflicts can ensue, and how best to address these tensions. Governments and institutions should thus alter relevant policies and devote more resources to addressing clinicians’ psychological strains. Institutions should also improve organizational culture. Public health organizations and the media described clinicians, earlier in the pandemic, as heroes, committed to treating COVID patients. This narrative should now be changed to highlight the strains that unvaccinated patients cause—endangering hospital staff and others.ConclusionsUnvaccinated COVID patients should receive care, but multi-level strategies, involving enhanced policies, education and practice are vital to alleviate ensuing moral distress, and thus aid these clinicians and their patients. Ethical arguments that providers must treat these patients have not considered these obligations’ effects on clinicians, but should do so. (shrink)

AbstractBackgroundEthical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. MethodsThe study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by (...) emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim.ResultsThe participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks.ConclusionFrom the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems. (shrink)

ZusammenfassungDie aktuellen Entwicklungen und Anforderungen in der pflegeberuflichen Bildung, das Ausbildungsziel im Pflegeberufegesetz vom 17. Juli 2017 und die Explikationen in der dazugehörigen Ausbildungs- und Prüfungsverordnung für die Pflegeberufe fordern eine stärkere Ausrichtung auf die Entwicklung ethischer Kompetenzen explizit ein. Bislang liegen tendenziell übergreifende Definitionen und Darlegungen zu ethischen Kompetenzen in der Pflege vor, deren Verdienst es ist, das Spezifische der Pflegeethik zu konturieren und erstmals ethische Kompetenzen für das Feld zu konkretisieren. In methodischer und didaktischer Hinsicht ist indes eine (...) spezifische Differenzierung gemäß unterschiedlicher Bildungsniveaus relevant. Lehrende werden ihre Lehre nicht mehr nur im Sinne einer allgemeinen Förderung ethischer Kompetenz entwickeln können, sondern müssen dabei den jeweiligen Verantwortungsbereich und das angezielte Qualifikationsniveau der Lernenden berücksichtigen. Ziel der Darlegungen ist es, konkrete Kompetenzniveaus für die Anbahnung professionsethischer Kompetenzen zu operationalisieren, die einerseits die Anforderungen aus dem zukünftigen Pflegeberufegesetz aufgreifen und andererseits anstehende curriculare Entwicklungsprozesse unterstützen. (shrink)

Key commentators on person‐centred care have described it as a “new ethic of care” which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person‐centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person‐centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to (...) comply more often with prevailing norms than those championed by person‐centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses’ ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person‐centred care. We argue that nurses’ responses to the ethical demand by way of parrhêsia can be an important feature of intra‐organizational reflexivity and its transformation towards the delivery care that is more person‐centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research. (shrink)

Background: Preparing tomorrow’s healthcare workforce for managing the growing complexity of care places high demands on students, educators, and faculties. In the light of worrying data about study-related stress and burnout, understanding how students manage stressors and develop resilience has been identified as a priority topic of research. In addition to study-related stressors, also moral stressors are known to characterize the students’ first clinical experiences. Objectives: However, current debates show that it remains unclear how healthcare ethics education should address them. (...) In order to clarify this issue, this study first develops the notion of moral resilience as a response to moral stressors involving both situations of moral complexity and moral wrongness. Second, it explores the potential of healthcare ethics education in fostering moral resilience. For this purpose, it defines moral resilience operationally as a reduction of moral distress in a given axis of time measured by a validated tool. Research design, participants, and context: The educational transferability was assessed within an explorative, quantitative pre–post interventional study with a purposive sample of 166 nursing students. The educational intervention comprised a lecture introducing the typology of moral stressors. Before and after the lecture, students were presented vignettes depicting morally stressful situations. Ethical considerations: The competent research ethics committee confirmed that no ethical approval was needed. Informed consent was obtained from participants. Findings: Three of four vignettes showed a modest but statistically significant reduction in measured levels of distress after the lecture (p < 0.05, α = 5%). Discussion: The study shows the potential of healthcare ethics education in providing students with transformative knowledge that fosters moral resilience. Conclusion: In times of global scarcity of educational resources, healthcare ethics education has an important contribution to offer in the promotion of students’ mental and physical health by strengthening the knowledge base of moral resilience. This legitimates its costs for societies, faculties, and professional bodies. (shrink)

Background: The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making. Research Question/Aim: To discover how effective the participants perceived the program and if their goals of participation had been met. Research design: A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to (...) graduates. Ethical considerations: Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted. Findings: An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a “moral compass to navigate the many gray areas of decision-making that confront them in daily practice.” Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process. Discussion: Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency. Conclusion: Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making. (shrink)

Background: Moral distress can be broadly described as the psychological distress that can develop in response to a morally challenging event. In the context of healthcare, its effects are well documented in the nursing profession, but there is a paucity of research exploring its relevance to healthcare assistants. Objective: This article aims to examine the existing research on moral distress in healthcare assistants, identity the important factors that are likely to contribute to moral distress, and propose preventative measures. Research Design: (...) This is a survey of the existing literature on moral distress in healthcare assistants. It uses insights from moral distress in nursing to argue that healthcare assistants are also likely to experience moral distress in certain contexts. Participants and Research Context: No research participants were part of this analysis. Ethical Considerations: This article offers a conceptual analysis and recommendations only. Findings: The analysis identifies certain factors that may be particularly applicable to healthcare assistants such as powerlessness and a lack of ethical knowledge. We demonstrate that these factors contribute to moral distress. Discussion: Recommendations include various preventative measures such as regular reflective debriefing sessions involving healthcare assistants, nurses and other clinicians, joint workplace ethical training, and modifications to the Care Certificate. Implementation of these measures should be monitored carefully and the results published to augment our existing knowledge of moral distress in healthcare assistants. Conclusion: This analysis establishes the need for more research and discussion on this topic. Future research should focus on evaluating the effectiveness of the proposed recommendations. (shrink)

Background: Human health is dependent upon environmental sustainability. Many have argued that environmental sustainability advocacy and environmentally responsible healthcare practice are imperative healthcare actions. Research questions: What are the key obstacles to healthcare professionals supporting environmental sustainability? How may these obstacles be overcome? Research design: Data-driven thematic qualitative analysis of semi-structured interviews identified common and pertinent themes, and differences between specific healthcare disciplines. Participants: A total of 64 healthcare professionals and academics from all states and territories of Australia, and multiple (...) healthcare disciplines were recruited. Ethical considerations: Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were de-identified to protect participant anonymity. Findings: Qualitative analysis indicated that Australian healthcare professionals often take more action in their personal than professional lives to protect the environment, particularly those with strong professional identities. The healthcare sector’s focus on economic rationalism was a substantial barrier to environmentally responsible behaviour. Professionals also feared conflict and professional ostracism, and often did not feel qualified to take action. This led to healthcare professionals making inconsistent moral judgements, and feeling silenced and powerless. Constraints on non-clinical employees within and beyond the sector exacerbated these difficulties. Discussion: The findings are consistent with the literature reporting that organisational constraints, and strong social identification, can inhibit actions that align with personal values. This disparity can cause moral distress and residue, leading to feelings of powerlessness, resulting in less ethical behaviour. Conclusion: The data highlight a disparity between personal and professional actions to address environmental sustainability. Given the constraints Australian healthcare professionals encounter, they are unlikely to shift to environmentally responsible practice without support from institutions and professional associations. Professional development is required to support this endeavour. The poor transference of pro-ecological behaviour from one setting to another is likely to have international implications for healthcare practice. (shrink)

Background The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity. Objectives To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral distress and (...) career identity among nurses. Design A quantitative, cross-sectional study. Methods A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses’ Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement. Ethical consideration Research ethics approval was obtained from the researcher’s university and hospital where this study was conducted prior to data collection. Findings Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity ( β = −0.230 to −0.163, p < 0.01). Discussion The findings reveal a relationship between moral distress, moral courage, and career identity among nurses. Conclusion By paying attention to nurses’ moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses. (shrink)

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, as well (...) as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses. (shrink)

Background: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review Methods: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. (...) Results: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended. (shrink)

Background: Moral distress is increasingly recognized as a problem affecting healthcare professionals, especially nurses. If not addressed, it may create job dissatisfaction, withdrawal from the moral dimensions of patient care, or even encourage one to leave the profession. Spiritual well-being is a concept which is considered when dealing with problems and stress relating to a variety of issues. Objective: This research aimed to examine the relationship between spiritual well-being and moral distress among a sample of Iranian nurses and also to (...) study the determinant factors of moral distress and spiritual well-being in nurses. Research design: A cross-sectional, correlational design was employed to collect data from 193 nurses using the Spiritual Well-Being Scale and the Moral Distress Scale-Revised. Ethical considerations: This study was approved by the Regional Committee of Medical Research Ethics. The ethical principles of voluntary participation, anonymity, and confidentiality were considered. Findings: Mean scores of spiritual well-being and moral distress were 94.73 ± 15.89 and 109.56 ± 58.70, respectively. There was no significant correlation between spiritual well-being and moral distress ( r = −.053, p =.462). Marital status and job satisfaction were found to be independent predictors of spiritual well-being. However, gender and educational levels were found to be independent predictors for moral distress. Age, working in rotation shifts, and a tendency to leave the current job also became significant after adjusting other factors for moral distress. Discussion and conclusion: This study could not support the relationship between spiritual well-being and moral distress. However, the results showed that moral distress is related to many elements including individual ideals and differences as well as organizational factors. Informing nurses about moral distress and its consequences, establishing periodic consultations, and making some organizational arrangement may play an important role in the identification and management of moral distress and spiritual well-being. (shrink)

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and (...) PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes. (shrink)

Moral distress is prevalent within the neonatal intensive care unit (NICU) and can negatively affect clinicians. Studies have evaluated the causes of moral distress and interventions to mitigate it...

Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due (...) to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers’ evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as ‘a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments’. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress. (shrink)

Moral distress is a fundamental problem in the nursing profession that affects nurses. Critical care nurses are more susceptible to this problem due to the nature of their work. Moral distress may, in turn, lead to several undesirable consequences. This study aimed to determine the relationship between moral distress and intention to leave the ward among critical care nurses. This descriptive-correlational study was conducted by census method on all eligible nurses who worked in Coronary Care Unit (CCU) and Intensive Care (...) Unit (ICU) of AhVaz hospitals, Iran. Data was collected by Corley’s moral distress questionnaire and a researcher-made questionnaire to investigate the intention to leave the ward. Questionnaires were completed through self-report and data were analyzed using a t-test and Pearson correlation coefficient. The results showed that there was a direct association between moral distress and intension to leave the ward in critical care nurses (P < 0.05). Also, the intensity of moral distress (P = 0.03) and the intention to leave the ward (P = 0.007) were significantly higher in ICU nurses. Given the high exposure of critical care nurses with moral distress and its association with leaving the ward, it seems that devising strategies to reduce or control moral distress and its negative consequences are necessary, particularly in ICU nurses. (shrink)

Background The ethical competence of head nurses plays a pivotal role in nursing ethics. Ethical climate is a prerequisite for ethical competence, and moral resilience can positively influence an individual’s ethical competence. However, few studies have focused on the relationship between ethical climate, moral resilience, and ethical competence among them. Objectives To investigate the relationship between ethical climate, moral resilience, and ethical competence, and examine the mediating role of moral resilience between ethical climate and ethical competence among head nurses. Design (...) A quantitative, cross-sectional study. Methods A total of 309 Chinese head nurses completed an online survey, including ethical climate questionnaire, Rushton moral resilience scale, and ethical competence questionnaire. Inferential statistical analysis includes Pearson’s correlation and a structural equation model. Ethical considerations This study received ethical approval from the Institutional Review Board of Xiangya Nursing School of Central South University (No. E2023146). Results Head nurses’ ethical climate score positively impacted ethical competence (r = 0.208, p <.001), and ethical climate could affect ethical competence through the mediating role of moral resilience. Conclusion This study emphasized the value of ethical climate in moral resilience of head nurses, ultimately leading to an enhancement in their ethical competence. (shrink)

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. (shrink)

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long‐term consequences to the individual. Critical care areas are fraught with ethical issues, and end‐of‐life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses (...) when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality. (shrink)

Through the vehicle of Nicolas Sarkozy’s so-called “Dakar Address” we will analyse the West’s persisting lack of insight into the need for a Western decolonization. We will try to identify the dangers that come from this refusal, such as the abidance in colonial patterns, the enduring self-understanding as superior com-pared to Africa, and the persisting unwillingness to accept the colonial guilt. Decolonization has to be understood as a two-fold business. Decolonization is over-coming endured and perpetrated violence. It is not only (...) important that the colonial oppressed regain strength, it is equally important that the perpetrator of colonial violence understand their excess of violence and work on effecting its return impossible. We explain how Western thinking remains dangerous and untrustwor-thy if it refuses its own decolonization. Finally, we will draw attention to a fundamental pattern of Western thought that clashes with the fundamental values of the West: contempt. In a final step we suggest how this contempt can be overcome through desuperiorisation and the establishment of elative ethics. (shrink)

Background: Moral distress has been experienced by about 67% of critical care nurses which causes many complications such as job dissatisfaction, loss of capacity for caring, and turnover for nurses and poor quality of care for patients as well as health system. Objective: The purpose of this research was to provide a moral empowerment program to nursing directors, school of nursing, and the heads of hospitals to reduce moral distress in nurses and improve the quality of care. Methods: This research (...) was a randomized clinical trial conducted in two groups and three stages before, after 2 weeks, and 1 month after the intervention in order to evaluate the changes in moral distress of 60 nurses working in adults’ intensive care unit wards of Al-Zahra teaching hospital of Isfahan University of Medical Sciences. Data were collected using the standard Hamric’s Moral Distress Scale (2012) and analyzed using SPSS software version 22. Ethical considerations: This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran. Results: Results showed that in the three stages, there was no significant difference between the mean score of moral distress before (4.12 ± 2.70), 2 weeks after (4.23 ± 2.70), and 1 month after the intervention (4.04 ± 2.54) in the control group (p > 0.05), while in the experimental group, there was a significant difference between the three stages (p 0.05). However, this score significantly decreased 1 month after the intervention (2.64 ± 2.23; p < 0.05). Conclusion: In this research, it was observed that moral empowerment program has been effective in reducing the mean score of moral distress. Therefore, it is recommended that nursing managers and hospital directors implement empowerment program, in order to reduce the moral distress of nurses and improve the quality of care. (shrink)

Nurses may, and often do, experience moral distress in their careers. This is related to the complicated work environment and the complex nature of ethical situations in everyday nursing practice. The outcomes of moral distress may include psychological and physical symptoms, reduced job satisfaction and even inadequate or inappropriate nursing care. Moral distress can also impact retention of nurses. Although research has grown considerably over the past few decades, there is still a great deal about this topic that we do (...) not know including how to deal well with moral distress. A critical key step is to develop a deeper understanding of relational practice as it pertains to moral distress. In this article, exploration of the experience of moral distress among nurses is guided by the key elements of relational ethics. This ethical approach was chosen because it recognizes that ethical practice is situated in relationships and it acknowledges the importance of the broader environment on influencing ethical action. The findings from this theoretical exploration will provide a theoretical foundation upon which to advance our knowledge about moral distress. (shrink)

IntroductionWhen professional nurses face an obstacle in their perfect purposes, they would experience moral distress which is a suffering situation. This study aims at exploring conditions which lead to high levels of moral distress for nursing personnel within a teaching hospital in Iran.MethodsAll nursing staffs worked in ICU, CCU, open heart surgery and emergency ward of a teaching hospital in Mashhad, Iran, were evaluated in a descriptive study by translated and modified moral distress questionnaire of Corley.ResultsAccording to the participants, the (...) mean age and work experience were 34.15 ± 4.17 and 10.77 ± 4.06, respectively. Almost 91.5% of nurses had a bachelor degree, and 51.1% of them were female. The most amount of moral distress was identified in contribution to physicians who have not enough skills, disregarding patients' right, and the inability for providing drugs.DiscussionPost-CCU and assistant nurses, especially female individuals had higher scores of moral distress compare with others... (shrink)