Background Moral distress is a common challenge among professional nurses when caring for their patients, especially when they need to make rapid decisions. Therefore, leaving moral distress unconsidered may jeopardize patient quality of care, safety, and satisfaction. Aim To estimate moral distress among nurses. Methods This systematic review and meta-analysis conducted systematic search in Scopus, PubMed, ProQuest, ISI Web of Knowledge, and PsycInfo up to end of February 2022. Methodological quality of included studies was assessed using the Newcastle Ottawa checklist. (...) Data from included studies were pooled by meta-analysis with random effect model in STATA software version 14. The selected key measure was mean score of moral distress total score with its’ 95% Confidence Interval was reported. Subgroup analyses and meta-regressions were conducted to identify possible sources of heterogeneity and potentially influencing variables on moral distress. Funnel plots and Begg’s Tests were used to assess publication bias. The Jackknife method was used for sensitivity analysis. Ethical consideration The protocol of this project was registered in the PROSPERO database under decree code of CRD42021267773. Results Eighty-six manuscripts with 19,537 participants from 21 countries were included. The pooled estimated mean score of moral distress was 2.55 on a 0–10 scale [95% Confidence Interval: 2.27–2.84, I2: 98.4%, Tau2:0.94]. Publication bias and small study effect was ruled out. Moral distress significantly decreased in the COVID-19 pandemic versus before. Nurses working in developing countries experienced higher level of moral distress compared to their counterparts in developed countries. Nurses' workplace (e.g., hospital ward) was not linked to severity of moral disturbance. Conclusion The results of the study showed a low level of pooled estimated score for moral distress. Although the score of moral distress was not high, nurses working in developing countries reported higher levels of moral distress than those working in developed countries. Therefore, it is necessary that future studies focus on creating a supportive environment in hospitals and medical centers for nurses to reduce moral distress and improve healthcare. (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 Professional ethics is the regulation and discipline of nurses’ daily nursing work. Nurses often encounter various ethical challenges and problems in their clinical work, but there are few studies on nurses' adherence to professional ethics. Research Aim An analysis of nursing adherence to nursing ethics from the perspective of clinical nurses in the Chinese public health system. Research Design This study adopts the grounded theory approach proposed by Strauss and Corbin. Participants and research context Between July 2021 and January (...) 2022, Clinical nurses were recruited for online video interviews using purposive and theoretical sampling methods in seven hospitals in Beijing, Tianjin, Shanxi, Henan, Guangdong, and Fujian, China. Data analysis was conducted using Strauss and Corbin’s coding approach. Ethical considerations This study was approved by the Ethics Committee of Sanming First Hospital (MingYiLun 71/2021) Findings A total of 27 participants were included. A theoretical model of nursing staff adherence to professional ethics was constructed. The main core was adherence to professional ethics and the other cores were (1) causal conditions: professional ethics code, individual conscience; (2) intervening conditions: personal growth, social support system, matching career compensation, prediction of adverse consequences; (3) action strategies: sticking to professional values, self-regulation, flexible response, post-event improvement; and (4) outcomes: self-harmony, reduced medical disputes. Conclusions This study provides an interpretive understanding of why clinical nurses adhere to professional ethics in China and describes the challenges and issues posed by nurses’ use of strategies to cope with ethical adversity. The findings can be used to develop future complex studies. (shrink)

Background: Ethical leadership is important for developing ethical healthcare practice. However, there is little research-based knowledge on how to stimulate and educate for ethical leadership. Objectives: The aim was to develop and investigate the feasibility of a 6-week web-based, ethical leadership educational programme and learn from participants’ experience. Training programme and research design: A training programme was developed consisting of (1) a practice part, where the participating middle managers developed and ran an ethics project in their own departments aiming at (...) enhancing the ethical mindfulness of the organizational culture, and (2) a web-based reflection part, including online reflections and coaching while executing the ethics project. Focus group interviews were used to explore the participants’ experiences with and the feasibility of the training. Participants and research context: Nine middle managers were recruited from a part-time master’s programme in leadership in Oslo, Norway. The research context was the participating leaders’ work situation during the 6 weeks of training. Ethical considerations: Participation was voluntary, data anonymized and the confidentiality of the participating leaders/students and their institutions maintained. No patient or medical information was involved. Findings: Eight of the nine recruited leaders completed the programme. They evaluated the training programme as efficient and supportive, with the written, situational feedback/coaching as the most important element, enhancing reflection and motivation, counteracting a feeling of loneliness and promoting the execution of change. Discussion: The findings seem consistent with the basic assumptions behind the educational design, based partly on e-health research, feedback studies and organizational ethics methodology, partly on theories on workplace learning, reflection, recognition and motivation. Conclusion: The training programme seems feasible. It should be adjusted according to participants’ proposals and tested further in a large-scale study. (shrink)

Background Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL’s experience. Research aim The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress. Research design A qualitative descriptive (...) design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection. Participant and research context Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023. Ethical considerations This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection. Findings UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress. Conclusions The UBCCNL’s experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed. (shrink)

Introduction: Critical care nurses work in a complex and stressful environment with diverse norms, values, interactions, and relationships. Therefore, they inevitably experience some levels of ethical conflict. Aim: The aim of this study is to analyze the relationship of ethical conflict with personal and organizational characteristics among critical care nurses. Methods: This descriptive-correlational study was conducted in 2017 on a random sample of 216 critical care nurses. Participants were recruited through stratified random sampling. Data collection tools were a demographic and (...) professional characteristics questionnaire, the Ethical Conflict in Nursing Questionnaire-Critical Care Version, and the Organizational and Managerial Factors Questionnaire. The data were analyzed using the SPSS software (v. 22.0). Ethical considerations: All participants were informed about the study’s aim and were assured that participation in and withdrawal from the study would be voluntary. Findings: The mean score of exposure to ethical conflict was 201.91 ± 80.38. The highest-scored conflict-inducing clinical situation was “working with professionally incompetent nurses or nurse assistants.” Married nurses, nurses with official employment, nurses with master’s degree, and nurses with the history of attending ethics education programs had significantly higher exposure to ethical conflict than the other nurses (p < 0.05). The significant predictors of exposure to ethical conflict were marital status, educational status, reward system, organizational culture, manager’s conduct, and organizational structure and regulations (p < 0.05). These predictors accounted for 37.2% of the total variance of exposure to ethical conflict. Conclusion: Critical care nurses experience moderate levels of exposure to ethical conflict. A wide range of personal and organizational factors can contribute to such exposure, the most significant of which is the professional incompetence of nursing colleagues, nurse assistants, and physicians. Therefore, many improvements at personal and organizational levels are needed to reduce critical care nurses’ exposure to ethical conflict. (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)

Moral distress among nurses is well researched and well documented, but there is limited research on the moral distress experienced by care leaders, who serve as intermediaries between patient care nurses and higher levels of administration. Healthcare professionals experience moral distress daily in the context of older adult care. The aim of this scoping review was to evaluate recent literature on moral distress in older adult care with the goal of revealing how care leaders’ experiences of moral distress in older (...) adult care have been conceptualized in earlier studies. The research questions were: How is the concept of moral distress as experienced by care leaders in older adult care defined in the existing literature? How is the concept of moral distress conceptualized in the literature? The research has been conducted in accordance with the guidelines set forth by the Finnish National Advisory Board on Research Ethics TENK. We saw that consensus on how moral distress is defined is lacking. Care leaders in older adult care experience substantial moral distress, which could be linked to the duality of their leadership role. Moral distress can be caused by a complex interplay of individual and structural factors and the challenging complex moral issues inherent to older adult care. Moral distress could impact care leaders’ emotional health, job performance, overall job satisfaction and result in higher turnover rates, absenteeism, decreased quality of patient care, and increased organizational costs. Addressing moral distress on the individual, team, and organizational levels is crucial for enhancing care leaders’ well-being and improving the overall quality of care for older adults. A focus on the identification of strategies whereby care leaders can be supported, exploration of the long-term effects of moral distress on healthcare professionals in general, and the organizational outcomes associated with moral distress should be included in future research. (shrink)

Background Middle managers play a key role in promoting a caring culture in nursing homes. However, there is limited knowledge about middle managers’ inner motives and their experiences of their responsibility in developing a caring culture. Research aim The aim of the study is to get a deeper understanding of middle managers’ motives and their experiences of their responsibility to develop a caring culture in nursing homes. Research design A qualitative design with a hermeneutic approach inspired by Gadamer was chosen (...) which guided the interpretation of data. Qualitative semi-structured interviews were conducted. Participants and research context Data were collected from thirteen middle managers in nursing homes, in six municipalities in northern Norway in September and October 2021. Ethical considerations The study was approved by the Norwegian Centre for Research Data. Oral and written informed consent was obtained from participants. Findings The findings show that the middle managers had non- egoistic motives to promote a caring culture as expressed in their attitudes and actions. They felt responsible to promote a caring culture where both patients and staff experienced care and were respected and recognized as unique individuals. Middle managers as good role models are responsible for being present and raising awareness of the importance of care in the nursing home culture by systematically reflecting on care values. However, a strong focus on the financial and administrative demands limits the middle managers’ possibilities to promote a caring culture and prevented them from always acting as they wanted to act, which often causes moral distress. Conclusion Being in contact with inner motives, enables the leader to promote a homelike and caring culture where both patients and staff feels respected and recognized as unique individuals. This study highlights the importance of systematic reflection on caring values in nursing homes which leads to value awareness among all actors. (shrink)

Background:Ethical leadership is important for developing ethical healthcare practice. However, there is little research-based knowledge on how to stimulate and educate for ethical leadership.Objectives:The aim was to develop and investigate the feasibility of a 6-week web-based, ethical leadership educational programme and learn from participants’ experience.Training programme and research design:A training programme was developed consisting of a practice part, where the participating middle managers developed and ran an ethics project in their own departments aiming at enhancing the ethical mindfulness of the (...) organizational culture, and a web-based reflection part, including online reflections and coaching while executing the ethics project. Focus group interviews were used to explore the participants’ experiences with and the feasibility of the training.Participants and research context:Nine middle managers were recruited from a part-time master’s programme in leadership in Oslo, Norway. The research context was the participating leaders’ work situation during the 6 weeks of training.Ethical considerations:Participation was voluntary, data anonymized and the confidentiality of the participating leaders/students and their institutions maintained. No patient or medical information was involved.Findings:Eight of the nine recruited leaders completed the programme. They evaluated the training programme as efficient and supportive, with the written, situational feedback/coaching as the most important element, enhancing reflection and motivation, counteracting a feeling of loneliness and promoting the execution of change.Discussion:The findings seem consistent with the basic assumptions behind the educational design, based partly on e-health research, feedback studies and organizational ethics methodology, partly on theories on workplace learning, reflection, recognition and motivation.Conclusion:The training programme seems feasible. It should be adjusted according to participants’ proposals and tested further in a large-scale study. (shrink)

Aims and Objectives The purpose of this paper was to clarify the concept of ethical conflict in nursing and highlight the importance of tackling this issue. -/- Background Ethical conflict is on the rise in the nursing context. It is associated with the compromise of nurses' well-being and patient care. However, there is no thorough conceptual understanding of this concept. -/- Design Concept analysis. -/- Methods Databases (PubMed, PsycINFO, CINAHL, Scopus, Embase, Web of Science and SocINDEX) were searched for studies (...) between 1984 and 2021. Both quantitative and qualitative studies related to ethical conflict in nursing were included. Walker and Avant's method of concept analysis was used to identify the defining attributes, antecedents and consequences of the concept of ethical conflict in nursing. We followed the PRISMA-ScR checklist to report the study. -/- Results Thirty studies were included for conceptualization. Defining attributes were divided into four categories: (1) emotional responses, (2) incompatible values, (3) competing interests and (4) ambiguous obligations. The antecedents were (1) ethical sensitivity, (2) negative ethical climate, (3) insufficient authority, (4) unrealistic expectations, (5) poor collaboration and (6) inadequate resources. The consequences were identified as (1) moral residue, (2) loss of identity, (3) professional burnout and (4) poor patient care. -/- Conclusions A unified conceptual model of ethical conflict in nursing shed light on the ethical issues nurses might come across in practice. Despite the fact that ethical conflict is inherently negative, we conceptualised this concept as a neutral fact and an opportunity for nursing action. The construct identification provides basis for both the development of practice and the development of staff support and education. (shrink)