Background During the first wave of the new coronavirus (COVID-19) pandemic, the sudden increase in hospitalised patients put medical facilities in southern Switzerland under severe pressure. During this time, bachelor’s degree programs in nursing, physiotherapy and occupational therapy were disrupted, and students in their second year were displaced. Students experienced the continuous reorganisation of their traineeship as healthcare facilities adapted to a climate of uncertainty. Purpose The aim of this study was to investigate the degree of moral distress and the (...) ethical issues most often encountered by physiotherapy, nursing and occupational therapy students enrolled in a traineeship during the first wave of the COVID-19 pandemic in southern Switzerland. Participants and research context The sample consisted of 102 participants, and the response rate was 81.6%. Research design Based on a pragmatic approach, a mixed-method with a convergent design was adopted. Data were collected between 30 April 2020 and 14 May 2020, via a survey administered to all occupational therapy, physiotherapy and nursing students in their fourth semester. Ethical considerations Given that no vulnerable persons were involved, the Ethics Committee of Southern Switzerland waived authorisation. However, all measures were put into place to protect participants by guaranteeing their anonymity and confidentiality. Results and discussion The data analysis showed that the main source for moral distress was ‘poor teamwork’ and that the moral issues encountered most often by students were related to the appropriateness of care and working conditions, with a clear reference to students’ own safety and that of their loved ones; the other concerns reported included the loss of learning opportunities and the perceived lack of technical knowledge and skills. Conclusions This survey offers a faithful overview of physiotherapy, nursing and occupational therapy students’ experience during the first pandemic wave. This study also identifies some key recommendations for healthcare professions’ education. (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)

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)

The concept of moral distress comes from nursing ethics, and was initially defined as ‘…when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. (...) We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation. (shrink)

Professionelles Handeln bedarf moralischen Handlungsvermögens. Im Kontext pflegerischer Weiterbildungen beschreibt der Philosoph Andrew Jameton vor über drei Jahrzehnten psychologische Reaktionen auf kompromittiertes moralisches Handlungsvermögen, die er als moralischen Stress definiert. Diese Standarddefinition hat in der Pflegewissenschaft zu einer dichten Forschung geführt und zum Vorschlag einer weiten Definition. Belegt sind gravierende Folgen von moralischem Stress auf die Patientensicherheit und auf die psychische Gesundheit von Mitarbeitenden. Der Beitrag diskutiert die Rezeption des Konzepts innerhalb der Pflegewissenschaft und die jüngst vorgeschlagene weite Definition von (...) moralischem Stress als Reaktion auf Situationen wahrgenommener moralischer Unerwünschtheit. Er bezweifelt die Kongruenz der Definitionen. Gerade das Verständnis der Prävalenz von moralischem Stress in der Pflegepraxis wird durch die Ausweitung der Definition erschwert, welche den Messinstrumenten jeweils zugrunde liegt. Trotz dieser Unschärfe bleibt der Umgang mit moralischem Stress eine zentrale Herausforderung für alle Gesundheitsfachpersonen. Für die wirksame Bewältigung bedarf er aber einer Schärfung, die die Kernanliegen sowohl der „alten“ wie auch der „neuen“ Definition aufnimmt: Wahrgenommene moralische Unerwünschtheit wird als Gesamtheit an emotionalen Reaktionen auf ethisch belastende Situationen vorgeschlagen, der bei kompromittiertem moralischen Handlungsvermögen moralischer Stress folgen kann, bei erschwertem moralischen Handlungsvermögen hingegen moralisches Unbehagen. In normativer Hinsicht steht moralischer Stress für Reaktionen auf Situationen moralischer Komplizität, moralisches Unbehagen für solche auf moralischer Komplexität. Durch diese Schärfung wird moralischer Stress hinreichend klar bestimmbar und die Standarddefinition im Kern bestätigt. Aber auch das Anliegen der weiten Definition wird aufgenommen für das breite Spektrum ethischer Belastungen, die den Alltag von Gesundheitsfachpersonen prägen und spezifische Strategien zu deren Bewältigung erfordern. (shrink)

This paper introduces the concept of moral residue to global health, and shows how its presence undermines crucial interventions and research, especially in the global south. Lingering feelings of anxiety, anger, blame or frustration often exist among local populations, where previous interventions or research have left traces of harm and/or exploitation. The existence of such feelings reflects the presence of moral residue, recognizing the moral experiences of epistemic injustices, which in turn undermines critical interventions and research through outright rejection or (...) passive non-compliance among affected populations. While such situations have been variously interpreted and relevant strategies developed to address the issues, little to no consideration is made on the implications of moral residue experiences in global health contexts and how to address them. This paper demonstrates the presence of moral residue in global health and proffers an African ethical approach, a harmony framework, for addressing moral residue issues, as part of a holistic approach towards tackling population health crises without compromising health gains for affected populations in the global south. (shrink)

Aims: The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. Background: Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. Design: Systematic literature (...) review and narrative synthesis (November 2015–March 2016). Data sources: Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO® 1967–Present, CINAHL® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts. Review methods: Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. Results: In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. Conclusion: We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress. (shrink)

While researchers have examined the types of ethical issues that arise in long-term care, few studies have explored long-term care nurses’ experiences of moral distress and fewer still have examined responses to initial moral distress. Using an interpretive description approach, 15 nurses working in long-term care settings within one city in Canada were interviewed about their responses to experiences of initial moral distress, resources or supports they identified as helpful or potentially helpful in dealing with these situations, and factors that (...) hindered nurses in their responses. Using a thematic analysis process, three major themes were identified from the nurses’ experiences: (i) the context of the situation matters; (ii) the value of coming together as a team; and (iii) looking for outside direction. The work of responding to initial moral distress was more fruitful if opportunities existed to discuss conflicts with other team members and if managers supported nurses in moving their concerns forward through meetings or conversations with the team, physician, or family. Access to objective others and opportunities for education about ethics were also identified as important for dealing with value conflicts. (shrink)

Aims This study aims to examine the mediating effect of moral distress on the relationship between moral resilience and the intention to leave. Background Moral distress is a phenomenon that negatively impacts healthcare workers, healthcare institutions, and recipients. To eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience is important in protecting against the negative effects of moral distress, such as burnout and turnover intention. In this direction, it (...) is necessary to increase the moral resilience of nurses to reduce negative situations such as turnover intention in nurses. Methods It is a descriptive–predictive study. Sociodemographic Information Form, Measure of Moral Distress – Healthcare Professionals, and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 220 clinical nurses were recruited. Ethical considerations Approval was obtained from the university’s non-interventional ethics committee, and informed consent was obtained from the participants. Results The study found a total moral distress score of 6.39 ± 0.3.12 and moral resilience score of 2.69 ± 0.48. A moderate and weak negative correlation was found between moral distress and moral resilience. Moral distress has a moderating effect on the intention to leave nursing (β = −0.158, p =.010) and the intention to leave the current position (β = −0.174, p =.000). Individual’s moral resilience directly affects the intention to leave. The presence of moral distress eliminates the direct effect of moral resilience and affects the intention to leave together with moral resilience. Conclusions Moral resilience leads to decreased intention to leave, and moral distress mediates this situation. An increase in moral distress decreases moral resilience and increases intention to leave. It can be assumed that if moral distress is not controlled, increasing moral resilience will not affect the intention to leave the job. (shrink)

The SARS-CoV-2 pandemic has transgressed biomedical categories. According to Horton, it turned out to be a 'syndrome' that infected virtually all spheres of social life. The pandemic has created toxic social atmosphere highly unfavorable to clinical and clinic-ethical decision making. Constraints and pressures related to micro-, meso-, exo- and macro-environments framing doctors, nurses, and medical students in training were identified. These factors exacerbated moral distress (moral injury) amongst clinicians. In a joint Polish-Lithuanian project (IDUB 2020-2022) we examined predictors of moral (...) distress in pandemic clinical contexts. A survey-based, real-time, correlational and comparative study was conducted in Poland and Lithuania after the first year of pandemic with N=227 participants. Unexpected differences on regular and pandemic-type moral distress levels were found between the two national samples. Polish participants showed significantly higher moral distress levels than their Lithuanian counterparts. The following article discusses these findings and recommends the reinforcement of resilient medical decision making. (shrink)

Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral (...) doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves. (shrink)

Professionelles Handeln bedarf moralischen Handlungsvermögens. Im Kontext pflegerischer Weiterbildungen beschreibt der Philosoph Andrew Jameton vor über drei Jahrzehnten psychologische Reaktionen auf kompromittiertes moralisches Handlungsvermögen, die er als moralischen Stress definiert. Diese Standarddefinition hat in der Pflegewissenschaft zu einer dichten Forschung geführt und zum Vorschlag einer weiten Definition. Belegt sind gravierende Folgen von moralischem Stress auf die Patientensicherheit und auf die psychische Gesundheit von Mitarbeitenden. Der Beitrag diskutiert die Rezeption des Konzepts innerhalb der Pflegewissenschaft und die jüngst vorgeschlagene weite Definition von (...) moralischem Stress als Reaktion auf Situationen wahrgenommener moralischer Unerwünschtheit. Er bezweifelt die Kongruenz der Definitionen. Gerade das Verständnis der Prävalenz von moralischem Stress in der Pflegepraxis wird durch die Ausweitung der Definition erschwert, welche den Messinstrumenten jeweils zugrunde liegt. Trotz dieser Unschärfe bleibt der Umgang mit moralischem Stress eine zentrale Herausforderung für alle Gesundheitsfachpersonen. Für die wirksame Bewältigung bedarf er aber einer Schärfung, die die Kernanliegen sowohl der „alten“ wie auch der „neuen“ Definition aufnimmt: Wahrgenommene moralische Unerwünschtheit wird als Gesamtheit an emotionalen Reaktionen auf ethisch belastende Situationen vorgeschlagen, der bei kompromittiertem moralischen Handlungsvermögen moralischer Stress folgen kann, bei erschwertem moralischen Handlungsvermögen hingegen moralisches Unbehagen. In normativer Hinsicht steht moralischer Stress für Reaktionen auf Situationen moralischer Komplizität, moralisches Unbehagen für solche auf moralischer Komplexität. Durch diese Schärfung wird moralischer Stress hinreichend klar bestimmbar und die Standarddefinition im Kern bestätigt. Aber auch das Anliegen der weiten Definition wird aufgenommen für das breite Spektrum ethischer Belastungen, die den Alltag von Gesundheitsfachpersonen prägen und spezifische Strategien zu deren Bewältigung erfordern. (shrink)

Background: Individualized care is closely related to the fulfillment of nurses’ ethical responsibilities regarding the provision of healthcare as well as having a strong foundation in the philosophy of nursing. Objective: This study aimed to determine the association of job satisfaction and burnout with individualized care perceptions in nurses working at a university hospital located in the Central Black Sea region of northern Turkey. Research design: A cross-sectional correlational survey design. Participants and research context: The study was conducted between 15 (...) February 2017 and 15 August 2017 with 419 nurses working at a public university hospital located in Samsun. Data were collected using an information form, the Individualized Care Scale-Nurse Version, the Minnesota Job Satisfaction Scale, and the Maslach Burnout Inventory. The Mann–Whitney U test, Kruskal–Wallis test and Spearman Correlation were used. Ethical considerations: Ethical approval for the study was obtained from the Ondokuz Mayıs University Clinical Studies Board of Ethics. Oral informed consent was taken from the participants. Findings: There was a significant positive relationship between the total Individualized Care Scale-A Nurse Version score and the General Satisfaction subscale score of the Minnesota Job Satisfaction Scale (r = 0.121, p < 0.05). The total Individualized Care Scale-A Nurse Version score increased as the General Satisfaction subscale score of the Minnesota Job Satisfaction Scale increased. There was a significant negative relationship between the total Individualized Care Scale-B Nurse Version score and the Desensitization (r = –0.143, p < 0.01) and Personal Achievement subscale scores of the Maslach Burnout Inventory (r = –0.182, p < 0.01). The Desensitization and Personal Achievement subscale scores of the Maslach Burnout Inventory increased as the total Individualized Care Scale-B Nurse Version score decreased. Discussion: Factors associated with the individualized care perceptions of nurses, such as job satisfaction and burnout levels and factors related to personal life and worklife should be taken into consideration. Also in order to increase job satisfaction and motivation in nurses, personal preferences regarding the service they want to work at should be taken into account. Conclusion: Nurses with lower burnout and higher job satisfaction were found to have higher individualized care perceptions and to support the individuality of patients in care applications. It is important to consider work-related factors associated with individualized care perceptions, job satisfaction, and burnout in nurses. (shrink)

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (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)

Ethics teachers are regularly confronted with disturbing cases brought in by medical students in class. These classes are considered confidential, so that everyone can speak freely about their experiences. But what should ethics teachers do when they hear about a situation they consider to be outright alarming, for example where patients/students’ safety is at stake or where systematic power abuse seems to be at hand? Should they remain neutral or should they step in and intervene? In the Netherlands, as in (...) many other countries, there are no clear guidelines for ethics teachers on how to respond. To get more insight into what teachers themselves think a proper response would be, we interviewed 18 Dutch medical ethics teachers. We found that Dutch ethics teachers will address the issue in class, but that they are overall reluctant to intervene; take action outside the scope of class. This reluctance is partly rooted in the conviction that ethicists should stay neutral and facilitate reflection, instead of telling students or physicians what to do. At the same time, this neutral position seems a difficult place to leave for those teachers who would want to or feel they need to. This has to do with various organizational and institutional constraints tied up with their position. The study invites medical ethics teachers to reflect on these constraints together and think about how to proceed from there. This study seeks to contribute to research on cultural change in medicine and medical students’ experiences of moral distress. (shrink)

Background: The ethics and value bases in healthcare are widely acknowledged. There is a need to improve and raise awareness of ethics in complex systems and in line with competing needs, different stakeholders and patients’ rights. Evidence-based strategies and interventions for the development of procedures and practice have been used to improve care and services. However, it is not known whether and to what extent ethics can be developed using interventions. Objectives: To examine ethics interventions conducted on healthcare professionals and (...) healthcare students to achieve ethics-related outcomes. Research design: A systematic review. Methods: Five electronic databases were searched: CINAHL, the Cochrane Library, Philosopher’s Index, PubMed and PsycINFO. We searched for published articles written in English without a time limit using the keywords: ethic* OR moral* AND intervention OR program OR pre-post OR quasi-experimental OR rct OR experimental AND nurse OR nursing OR health care. In the four-phased retrieval process, 23 full texts out of 4675 citations were included in the review. Data were analysed using conventional content analysis. Ethical consideration: This systematic review was conducted following good scientific practice in every phase. Findings: It is possible to affect the ethics of healthcare practices through professionals and students. All the interventions were educational in type. Many of the interventions were related to the ethical or moral sensitivity of the professionals, such as moral courage and empowerment. A few of the interventions focused on identifying ethical problems or research ethics. Conclusion: Patient-related outcomes followed by organisational outcomes can be improved by ethics interventions targeting professionals. Such outcomes are promising in developing ethical safety for healthcare patients and professionals. (shrink)

Background: In the context of new reimbursement systems like diagnosis-related groups, moral distress is becoming a growing problem for healthcare providers. Moral distress can trigger emotional and physical reactions in nurses and can cause them to withdraw emotionally from patients or can cause them to change their work place. Objective: The aim of this pilot study was to develop an instrument to measure moral distress among acute care nurses in the German-speaking context, to test its applicability, and to obtain initial (...) indications of the instrument’s validity. Method: The study was designed in 2011 as a cross-sectional pilot survey. Conducted on eight units of one university hospital in German-speaking Switzerland, 294 registered nurses were asked to fill out a web-based questionnaire on moral distress. Ethical considerations: The study proposal was approved by the cantonal ethics committee. All participating nurses provided informed consent and were assured of data confidentiality. Results: The survey had a response rate of 55%. The results show the prevalence of statements on the questionnaire indicating situations with the potential to trigger moral distress. The entire range of answers was used in the responses. Most participants found the questionnaire comprehensible, while some criticized the phraseology of certain statements. Many more found the registration process prior to online access to be too time consuming. Nurses confirmed that the results reflect their subjective assessment of their situation and their experience of moral distress. Conclusion: The newly developed moral distress questionnaire appears to produce face validity and is sufficiently applicable for use in our study. The results indicate that moral distress appears to be a relevant phenomenon also in Swiss hospitals and that nurses were experiencing it prior to the introduction of Swiss diagnosis-related groups. (shrink)

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly—often with lingering effects such as healthcare providers’ disengagement and moral distress (McAndrew et al. Journal of (...) Trauma Nursing 18(4):221–230, 2011), compromised inter-professional relationships (Rosenstein and O’Daniel American Journal of Nursing, 105(1):54–64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1–11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486–490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results. (shrink)

Aims The study aims to test the Turkish validity and reliability of the Rushton Moral Resilience Scale (RMRS) and examine the effect of moral resilience on moral distress. Background Moral distress is a phenomenon that negatively affects health workers, health institutions, and the person receiving care. In order to eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience involves developing systems that support a culture of ethical practice in (...) healthcare and aim to increase an individual’s capacity to cope with moral challenges. Methods A methodological and descriptive-predictive study design was adopted. Sociodemographic Information Form, Measure of Moral Distress – Healthcare Professionals (MMD-HP), and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 255 clinical nurses were recruited. Ethical considerations Hacettepe University’s non-interventional ethics committee approved the study’s protocol and informed consent was obtained from the participants. Results The original four-factor structure of the scale was tested with confirmatory factor analysis, and the index values were evaluated and found at an acceptable level. The Cronbach Alpha coefficient of the scale was found to be 0.826. Moral resilience predicted moral distress total, intensity, and frequency levels. A moderate and weak relationship was found in the negative between all sub-dimensions of moral distress and moral resilience. Conclusions The Rushton Moral Resilience Scale Turkish version showed good psychometric properties. Moral resilience has a reducing effect on moral distress. Young nurses who have less experience are at risk because they have lower moral resilience levels, while nurses working in intensive care units are at risk because of their high moral distress levels. A healthy workplace can be created by developing specific approaches to improve moral resilience in reducing the impact of moral distress in the healthcare environment. (shrink)

The COVID‐19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID‐19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to (...) consider needs for additional support. Twenty semi‐structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges. (shrink)

The plethora of literature on moral distress has substantiated and refined the concept, provided data about clinicians’ (especially nurses’) experiences, and offered advice for coping. Fewer scholars have explored what makes moral distress _moral_. If we acknowledge that patient care can be distressing in the best of ethical circumstances, then differentiating distress and moral distress may refine the array of actions that are likely to ameliorate it. This article builds upon scholarship exploring the normative and conceptual dimensions of moral distress (...) and introduces a new tool to map moral distress from emotional source to corrective actions. The Moral Distress Map has proven useful in clinical teaching and ethics-related debriefings. (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)

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (shrink)

Aim: The aim of this review is to examine the ways in which the concept of moral distress has been delineated and deployed in the argument-based nursing ethics literature. It adds to what we already know about moral distress from reviews of the qualitative and quantitative research. Data sources: CINAHL, PubMed, Web of Knowledge, EMBASE, Academic Search Complete, PsycInfo, Philosophers’ Index and Socindex. Review methods: A total of 20 argument-based articles published between January 1984 and December 2013 were analysed. Results: (...) We found that like the empirical literature, most authors in this review draw on Jameton’s original definition and describe moral distress in psychological–emotional–physiological terms. They also agree that moral distress is linked to the presence of some kind of constraint on nurses’ moral agency, and that it is best understood as a two-staged process that can intensify over time. There is also consensus that moral distress has an important normative meaning, although different views concerning the normative meaning of moral distress are expressed. Finally, the authors generally agree that moral distress arises from a number of different sources and that it (mostly) affects negatively on nurses’ personal and professional lives and, ultimately, harms patients. However, despite this consensus, many authors take issue with the way in which moral distress is conceptualized and operationalized. Moreover, while some worry that identifying nurses as a group of health professionals whose voices are ignored or marginalized might disempower nurses and encourage them to avoid their moral responsibilities, others take situations involving moral distress as indicative of more fundamental, structural inequities at the heart of contemporary healthcare provision. Conclusion: We conclude that research on moral distress in nursing is timely and important because it highlights the specifically moral labour of nurses. However, we suggest that significant concerns about the conceptual fuzziness and operationalization of moral distress also flag the need to proceed with caution. (shrink)

Nurses are frequently confronted with ethical dilemmas in their nursing practice. As a consequence, nurses report experiencing moral distress. The aim of this review was to synthesize the available quantitative evidence in the literature on moral distress experienced by nurses. We appraised 19 articles published between January 1984 and December 2011. This review revealed that many nurses experience moral distress associated with difficult care situations and feel burnout, which can have an impact on their professional position. Further research is required (...) to examine worksite strategies to support nurses in these situations and to develop coping strategies for dealing with moral distress. (shrink)

Background: The research question for this study was as follows: Is the Code of Ethics for Nurses in Italy (Code) a valid or useful decision-making instrument for nurses faced with ethical problems in their daily clinical practice? Method: Focus groups were conducted to analyze specific ethical problems through 11 case studies. The analysis was conducted using sections of the Code as well as other relevant documents. Each focus group had a specific theme and nurses participated freely in the discussions according (...) to their respective clinical competencies. Ethical considerations: The executive administrative committee of the local nursing licensing council provided approval for conducting this project. Measures were taken to protect the confidentiality of consenting participants. Findings: The answer to the research question posed for this investigation was predominantly positive. Many sections of the Code were useful for discussion and identifying possible solutions for the ethical problems presented in the 11 cases. Conclusion: We concluded that the Code of Ethics for Nurses in Italy can be a valuable aid in daily practice in most clinical situations that can give rise to ethical problems. (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)

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)

Background: Since moral distress affects psychological aspects of psychiatric nurses, it is an important theme. Previous studies showed relationships between moral distress and job satisfaction; however, there are few studies which investigate relationships between moral distress and other effective variables and then we highlighted relationships among these variables. Objective: This study aimed to (1) examine relationships among moral distress, sense of coherence, mental health, and job satisfaction and (2) clarify the most predictive variable to job satisfaction. Research design: This study (...) is a cross-sectional study. Participants were 130 psychiatric nurses in a hospital in Japan. They completed the Moral Distress Scale for Psychiatric nurses (Unethical conduct, Low staffing, and Acquiescence to patients’ rights violations), the sense of coherence scale (Comprehensibility, Manageability, and Meaning), the General Health Questionnaire, and the Job Satisfaction scale. Ethical consideration: This study was approved by the ethical board of St Mary’s College. Nurses participated voluntarily and were anonymous. Results: Results showed that subscales of the Moral Distress Scale for Psychiatric nurses negatively correlated to the sense of coherence and the Job Satisfaction. A multiple regression analysis showed that “Acquiescence to patients’ rights violations” of the Moral Distress Scale for Psychiatric nurses and “Meaning” of the sense of coherence influenced the Job Satisfaction much more than other variables. These two variables were correlated to job satisfaction scale, and other variables without them did not significantly correlate to job satisfaction scale. Discussion: These results suggest that moral distress negatively related to sense of coherence and job satisfaction, a subscale of the Moral Distress Scale for Psychiatric nurses and that of the sense of coherence affected the job satisfaction the most. Conclusion: Decreasing of acquiescence to patients’ rights violations and finding meaning in nursing may improve job satisfaction. (shrink)

Objective Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)—perceived psychological safety, ethical climate, patient safety—and healthcare professionals’ perception of moral distress.Design Cross-sectional surveySetting Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States.Participants Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study.Main outcome measures Three dimensions of OCHC were (...) measured using validated questionnaires: Olson’s Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality’s Patient Safety Culture Survey, and Edmondson’s Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM).Results Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= −0.357, p <.001) and patient safety culture (β = −0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82).Conclusions We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations. (shrink)

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one (...) ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress. (shrink)

Background Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics. Objectives To explore factors influencing nursing documentation from nurses’ perspectives in the Iranian nursing context. Methods This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients’ medical files were used for data collection. Ethical considerations (...) This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent. Findings The main theme of this study was “unsafe documentation.” Two categories, “types of errors in reporting” and “reasons of errors in reporting,” and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context. Conclusion In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice. (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)

It is known that people have been getting distressed for a long‐time and healthcare workers, like the military, seem to fit criteria for being at particular risk. Fairly recently a term of art, moral distress, has been added to types of distress at work, though not restricted to work, they can suffer. There are recognized scales that measure psychological distress such as the General Health Questionnaire and the Kessler scales but moral distress it is claimed is different warranting its own (...) scale. This seems to be because of both the intensity and nature of moral problems encountered at work that is so powerful and so destructive of moral agency and integrity. This paper will focus on how, if at all, moral distress is different by examining the idea of moral normativity. Moral normativity is understood as roughly the sort of thing that all rational persons would endorse regardless of his interests, having an “automatic reason giving force” and is likely to also require an overriding force. Specifically, it will examine how this force of moral claims seems to be needed for moral distress to be so destructive of healthcare professional's moral agency and integrity. This is related to the idea of warrantedness of the reaction of distress. Even if morality had such a strong normativity, one can still ask is distress the correct or warranted reaction? It seems plausible that if distress is a correct response for it to be both moral and warranted it needs a strong account of moral normativity. The idea of a distinct form of distress as moral distress may be true in theory but is too contested both ontologically and epistemologically for a useful practice of measurement at present. (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 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)

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)

Objective: To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature. Design: A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants. Setting: A regional, tertiary academic referral hospital in Ontario offering a perinatal program. Participants: A total (...) of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants. Methods: Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants. Ethical considerations: Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis. Results: Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses’ perceived lack of power and influence in the neonatal resuscitation decision-making process. Conclusion: Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration. (shrink)

Background: The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction. Aim: Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. Research design: A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. Ethical considerations: Ethical approval granted (...) by the Regional Research Ethics Committee in Western Norway (131421). Findings: Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. Discussion: By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority. Conclusion: Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms. (shrink)

In the last three decades, considerable theoretical and empirical research has been undertaken on the topic of moral distress among health professionals. Understood as a psychological and emotional response to the experience of moral wrongdoing, there is evidence to suggest that—if unaddressed—it contributes to staff demoralization, desensitization and burnout and, ultimately, to lower standards of patient safety and quality of care. However, more recently, the concept of moral distress has been subjected to important criticisms. Specifically, some authors argue that the (...) standard account of moral distress elucidated by Jameton :542–551, 1984) does not refer to a discrete phenomenon and/or that it is not sufficiently broad and that this makes measuring its prevalence among health professionals, and other groups of workers, difficult if not impossible. In this paper, we defend the standard account of moral distress. We understand it as a concept that draws attention to the social, political and contextual determinants of moral agency and brings the emotional landscape of the moral realm to the fore. Given the increasing pressure on health professionals worldwide to meet efficiency, financial and corporate targets and reported adverse effects of these for the quality and safety of patient care, we believe that further empirical research that deploys the standard account moral distress is timely and important. (shrink)

Background Midwives and nurses appear vulnerable to moral distress when caring for women whose babies are removed at birth. They may experience professional dissatisfaction and their relationships with women, families and colleagues may be compromised. The impact of moral distress may manifest as anger, guilt, frustration, anxiety and a desire to give up their profession. While there has been much attention exploring the concept of moral distress in midwifery, this is the first study to explore its association in this context. (...) Aim This article explores midwives’ experiences of moral distress when providing care to women whose babies were removed at birth and gives valuable insight into an issue nurses and midwives encounter in their profession. Methods Four mothers and eight midwives took part in this research. Narrative inquiry incorporating photo-elicitation techniques was used to generate data; mothers were interviewed face to face and midwives through focus groups. The images and audio data were collected, transcribed and analysed for emerging themes. For the purpose of this article, only the midwives’ stories are reported. This research received a favourable ethical opinion from the University of Surrey Ethics committee. Ethical considerations This study received a favourable ethical approval from a higher education institutes ethics committee. Results Midwives who care for women whose babies are removed at birth report it as one of the most distressing areas of contemporary clinical practice. Furthermore, they report feelings of guilt, helplessness and betrayal of the midwife–mother relationship. Many of the midwives in this study state that these experiences stay with them for a long time, far more than more joyful aspects of their role. Conclusion Midwives experience moral distress. Support systems, education and training must be available to them if we are to reduce the long-term impact upon them, alleviate their distress and prevent them from leaving the profession. (shrink)

Background Moral distress is a phenomenon that all nurses experience at different levels and contexts. The level of moral distress can be affected by individual values and the local culture. The sources of the values shape the level of moral distress experienced and the nurses’ decisions. Aim The present scoping review was conducted to examine the situations that cause moral distress in ICU nurses in different countries. Results A scoping review methodology was adopted for the study, in line with the (...) approach of Arksey, and O'Malley Literature was searched within PubMed/Medline, Scopus, Web of Science, and PsycINFO indexed keywords such as “moral distress”, “Critical Care Nurse”, and “Moral Distress Scale-Revised”. Of the 617 identified citations, 12 articles matched the inclusion criteria. Conclusion The moral distress experienced in countries and regions with similar cultures and geographies was parallel. The situations that cause the most moral distress are futile-care to prolong death, unnecessary tests and treatments, and working with incompetent healthcare personnel. (shrink)

Background: Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses’ values, the physician–nurse power hierarchy, and the influence of the culture. Research objective: To analyze the main causes for moral distress with interpretive interactionism. Research design: A qualitative study was adopted. Participants: Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples. Ethical considerations: Approval from the Institutional Review Board of the Kaohsiung (...) Medical University Hospital. Findings: Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician–nurse power hierarchy, and the Oriental culture affect nurses’ goodness-based intention for patients, which deteriorates moral distress. Discussion: The main cause for moral distress is the moral goodness of nurses. If nurses’ goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients’ right to know about their diseases, the choice of treatment, and patients’ autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care. Conclusion: The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses’ confidence and cultural sensitivity, so as to reduce the moral distress of nurses. (shrink)

Background: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. Aim: To describe and analyze the phronesis applied by nurses in the face of moral distress. Research design: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to (...) interpret the nurses’ phronesis. Participants: Twenty-seven nurses from Taiwan. Ethical considerations: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. Findings: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse’s emotional movement. Action and idea transformation are collectively called phronesis in this study. Discussion: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. Conclusion: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress. (shrink)

Introduction/Background: Moral distress and related concepts surrounding morality and ethical decision-making have been given much attention in nursing. Despite the general consensus that moral distress is an affective response to being unable to act morally, the literature attests to the need for increased clarity regarding theoretical and conceptual constructs used to describe precisely what the experience of moral distress involves. The purpose of this study is to understand how student nurses experience morally distressing situations when caring for patients with different (...) values and beliefs than their own in the clinical environment -/- Methods: This study is based on secondary analysis of participant data. The stories of eight student nurses who completed the original study were reviewed following Yin’s multiple-case study design. -/- Results: Findings suggest there is a subtle form of moral distress that has been under appreciated in the literature and differs from Jameton’s classic definition. While traditional institutional triggers to moral distress are pervasive, personal conflict as a result of differing value systems may be a moral challenge faced by nursing students working with culturally diverse patients. -/- Conclusion: Ethics education is needed in nursing school to reduce moral distress in the clinical environment. Nursing students need opportunities to develop moral reasoning skills in addition to their clinical skills. A philosophical approach to ethics education may be needed to prevent and alleviate moral distress. (shrink)