These are strange and unprecedented times in the wake of the COVID-19 pandemic. Most frontline healthcare professionals have never witnessed anything like this before. As a result, staff may experience numerous and continuous traumatic events, which in many instances, will negatively affect their psychological well-being. Particularly, nurses face extraordinary challenges in response to shifting protocols, triage, shortages of resources, and the astonishing numbers of patients who require care in expedited time constraints. As most healthcare workers are passionate nursing professionals, frustration (...) and often a sense of powerlessness occur when they find themselves unable to provide needed care to their patients. The overwhelming number of deaths, patients isolated and dying alone, and the ever-present fear of being infected and then infecting colleagues, family, friends due to the lack of protective gear or known protocols takes its toll on emotional and psychological well-being. For nurses, the experience of this significant (hopefully once-in-a-lifetime) event can inflict on-going moral injury. Nurses affected by this trauma require education, coping tools, and therapy to help avoid or alleviate the adverse effects on their well-being. Institutions must provide these resources to tend to the well-being of their healthcare staff, during and beyond the pandemic. This article aims to investigate moral distress—considering it as a moral injury—and offer tools and recommendations to support healthcare nurses as they respond to this crisis and its aftermath. (shrink)

Background Ethics of care provides a framework for health care professionals to manage ethical dilemmas and moral resilience may mitigate stress associated with the process and outcomes of ethical reasoning. This review addresses the empirical study of ethics of care and moral resilience, published in the health care literature, and identifies potential research gaps. Methods and procedure Arksey O’Malley's framework was adopted to conduct this scoping review. A literature search was conducted across six databases: CINAHL Plus with full text, PubMed, (...) PsycINFO, EMBASE, Scopus and MEDLINE. We collected and synthesised information on the nature of studies including study design, methods and key findings. Results While there is an abundance of literature describing the potential strengths of an ethics of care approach to ethical reasoning and growing interest in the role of moral resilience in protecting against moral distress, both concepts have received little empirical attention. A total of six relevant publications were selected for review. No studies explored the relationship between ethics of care and moral resilience. However, studies focused upon ethics of care approach as a facilitator of patient-practitioner professional relationships and effective ethical decision making in health care practice. Current evidence explores key characteristics consistent with moral resilience in health care professionals. Conclusion This review identified a dearth of research in ethics of care and moral resilience in healthcare practice. Further empirical investigation may provide a deeper understanding of the translation of ethics of care and moral resilience to health care practice to facilitate workplace culture. (shrink)

Die Anforderungen an die ethische Kompetenzentwicklung im Rahmen der hochschulischen Pflegeausbildung sind anspruchsvoll und methodisch zu konkretisieren. Der Beitrag geht zunächst der Frage nach, wie Ethikkompetenz in Bezug auf die hochschulische Pflegeausbildung zu konturieren ist. Basierend auf dieser definitorischen Rahmung liegt das Augenmerk auf dem Prozess der Ethik-Leitlinienentwicklung als mögliche zu diskutierende Methode der Ethikkompetenzentwicklung. Hierbei ist die Frage leitend, ob der Prozess der Ethik-Leitlinienentwicklung im Rahmen des Studiums – analog zu den bis dato vielfach realisierten Fallanalysen – eine weitere (...) beziehungsweise ergänzende Methode der Ethikdidaktik sein könnte, um die für das professionelle Pflegehandeln relevanten Ethikkompetenzen im Rahmen der hochschulischen Pflegeausbildung anzubahnen und/oder zu verdichteten. (shrink)

In today’s highly dynamic societies, moral norms and values are subject to change. Moral change is partly driven by technological developments. For instance, the introduction of robots in elderly care practices requires caregivers to share moral responsibility with a robot (see van Wynsberghe 2013 ). Since we do not know what elements of morality will change and how they will change (see van der Burg 2003 ), moral education should aim at fostering what has been called “moral resilience” (Swierstra 2013 (...) ). We seek to fill two gaps in the existing literature: (i) research on moral education has not paid enough attention to the development of moral resilience; (ii) the very limited literature on moral resilience does not conceptualise moral resilience in relation to new technological developments. We argue that philosophical accounts of moral education need to do justice to the importance of moral resilience, and that a specific form of moral resilience should be conceptualised as “technomoral resilience” to underline the added value of cultivating moral resilience in relation to technomoral change. We illustrate the role of technomoral resilience in practice by looking at the context of elderly care. To make the first step towards an account of how technomoral resilience can be fostered in moral education, we propose that moral education shall focus on a triangle of capacities: (1) moral imagination, (2) a capacity for critical reflection, and (3) a capacity for maintaining one’s moral agency in the face of disturbances. (shrink)

There is a disproportionate number of complaints about social workers in England to the Health and Care Professionals Council (HCPC) as compared with the other health care professionals regulated by HCPC. This paper discusses findings from interviews and focus groups that formed part of a mixed methods study that aimed to find out the reasons for complaints and the strategies that may reduce complaints. Four themes were identified: social work as an evolving profession; social work involves challenging practice; social work (...) takes place in a pressurised environment; and public perceptions and expectations of social work are often negative and unrealistic. Findings highlight explanations that focus on organisational culture and public responses to social workers’ control functions. We argue that, at a time of change for the profession, there is a need for public education regarding the role and function of social workers and for regulators to have more proactive engagement with registrants and employers. (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)

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)

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)

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)

This article presents an ethics support instrument for healthcare professionals called CURA. It is designed with a focus on and together with nurses and nurse assistants in palliative care. First, we shortly go into the background and the development study of the instrument. Next, we describe the four steps CURA prescribes for ethical reflection: (1) Concentrate, (2) Unrush, (3) Reflect, and (4) Act. In order to demonstrate how CURA can structure a moral reflection among caregivers, we discuss how a case (...) was discussed with CURA at a psychogeriatric ward of an elderly care home. Furthermore, we go into some considerations regarding the use of the instrument in clinical practice. Finally, we focus on the need for further research on the effectiveness and implementation of CURA. (shrink)

Background A combination of theoretical and practical approaches is required to learn and acquire ethical competencies in caring. Occasionally, reflection on practical action differs from theoretical learning. In the context of reflective learning, issues such as ethical values can be discussed since they evoke conflict among nursing students. Aim To identify ethical conflicts encountered by nursing students during clinical placements and to determine their cooperation strategies. Research design Qualitative study with a content analysis according to Elo and Kinglas framework. Participants (...) and research context Students enrolled in a nursing program at a Spanish university aged between 22 and 35, mainly women. Methodology The study includes 134 ethical reflections from nursing students in the last year of the nursing program, written during their clinical practices in a variety of learning environments. The research team analyzed the reflections using an inductive content analysis method. Ethical considerations Ethical permission was obtained by the management center according to Law 3/2028, and all the participants accepted to participate through the informed consent form. Findings Three main categories emerged from the analysis of the ethical reflections: (1) evaluation of professional performance and patient care; (2) the student as the protagonist of the dilemma; (3) student coping. Student dilemmas and concerns are related to ignorance, student-patient communication, mistakes made and self-confidence. Some situations conflict with the autonomy of patients and their rights, and can contribute to stressful situations for patients. Stress factors include hospital routines, which the patient cannot modify, and asymmetric relationships with staff, which encourage passivity. Conclusion All ethical problems detected by the students begin with the professional-patient relationship, including issues related to bad news, errors or malpractice. Reflection on the ethical values of nursing, both in the classroom and in clinical practices, allows students to develop a greater ethical awareness of care, enhancing their decision-making skills in ethical dilemmas. (shrink)

Background: Most undergraduate midwifery curricula comprise ethics courses to strengthen the moral competences of future midwives. By contrast, surprisingly little is known about the specific moral competences considered to be relevant for midwifery practice. Describing these competences not only depends on generic assumptions about the moral nature of midwifery practice but also reflects which issues practitioners themselves classify as moral. Objective: The goal of this study was to gain insight into the ethical issues midwives encounter in their daily work, the (...) key competences and resources they consider indispensable to understand and deal with them, and to assess phenomena linked to moral distress. Methods: We conducted individual semi-structured interviews with eight midwives and two other health professionals, varying in terms of years of experience and work setting. Interview transcripts were analyzed in an interdisciplinary research group, following thematic analysis. Ethical considerations: This study was not subject to approval according to the Swiss Law on Research with Humans. Participants were informed about the study goals and gave written informed consent prior to participation. Results: External constraints limiting the midwife’s and the patient’s autonomy and resulting interpersonal conflicts were found to be the most relevant ethical issues encountered in clinical practice and were most often associated with moral distress. These conflicts often arise in the context of medical interventions midwives consider as not appropriate and situations in which less experienced midwives in particular observe a lack of both interprofessional communication and trust in their professional competence. Ethical issues related to late abortions or prenatal diagnostics and selective abortions were also frequently addressed, but many midwives involved had learned to cope with them. Discussion: In the light of the ethical issues and factors contributing to phenomena of moral distress, an empirically grounded profile of moral competences is drafted. Curricular implications in the light of possible adaptations within undergraduate midwifery education are critically discussed. (shrink)

Background: Midwives are required to make ethical decisions with the support of respective codes of professional ethics which provide a framework for decision making in clinical practice. While each midwife should be ethically aware and sensitive to the ever-changing issues within reproduction, few empirical studies have examined the views of student midwives in relation to reproductive ethical dilemmas. Objective: The aim of this study was to explore midwifery students’ reactions to a number of ethical dilemmas relating to women’s experiences of (...) reproductive decision making. Design: A series of focus groups were conducted with midwifery students who were asked to discuss five culturally significant scenarios including issues of knowledge acquisition regarding methods of family planning, removal or insertion of an intrauterine device, and abortion. Setting: A University in Turkey was the setting for this study. Participants: Purposeful sampling was adopted which resulted in five focus groups with a total of 57 midwifery students. Ethical considerations: The study was reviewed and granted formal ethical approval by an ethical committee at the Faculty of Health Science in Atatürk University. The head of the Faculty of Health Science approved the investigation. The participants received both oral and written information about the study and they gave their consent. Results: Five themes were identified from the analysis of the focus group data related to all five scenarios. These themes were ‘the right to information’, ‘choice and protection’, ‘parental rights and welfare of the women’, ‘make a decision’ and ‘women rights and sexual abuse’. Conclusion: This study has shown that while students respected women’s choice, they also expressed great ambivalence in some situations when personal values conflict with dominant societal beliefs and professional ethics. A focus on ethics education to include human rights is suggested as a means to enable students to explore their own social-value judgements, and as a means to limit the possible development of ethical confusion and 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)

Moral sensitivity is known to be the starting point for moral competence and even is a core concept in the curricula for bachelor’s-level nursing students in the Netherlands. While the development of moral sensitivity in nursing is commonly agreed to be important, there is no clear understanding of how to develop moral sensitivity through nursing education and what components of nursing education contribute to moral sensitivity. Studies on educational interventions could build knowledge about what works in developing moral sensitivity and (...) how to achieve this outcome. Therefore, the aim of this study is to explore if and how educational interventions contribute to the development of moral sensitivity in nursing students. A scoping review was conducted. Four electronic databases were searched: CINAHL, PubMed, MEDLINE and SpringerLink. Articles that were not about formal or initial nursing education and that had no link to moral development or moral sensitivity were excluded. After the final selection on educational interventions, 10 articles out of the initial 964 resources were included in the review. Three different but related dimensions of moral sensitivity emerged from the literature: (1) raising moral awareness, (2) providing the ability to frame and name ethical issues and (3) improving moral reasoning ability. Half of the studies used quantitative measures to evaluate the educational intervention, in particular the Moral Sensitivity Questionnaire; the other half used diverse qualitative evaluation methods. None of the studies presented teaching methods that included all three dimensions of moral sensitivity. Moral awareness of self appears to be more loosely connected to the other two dimensions, which raises the question of whether it can be seen as a prerequisite for them. To encompass all dimensions of moral sensitivity, a mix of quantitative and qualitative measures seems most appropriate to study that topic. (shrink)

Background Nurses often face ethical issues in their daily work that can have an impact on their level of job embeddedness. And positive job embeddedness is essential to reduce burnout among nurses and improve professional retention in the medical industry. However, few studies have focused on the relationship between moral distress, moral resilience, and job embeddedness. Objectives To investigate the relationship between moral distress, moral resilience, and job embeddedness, and explore the mediating role of moral resilience between moral distress and (...) job embeddedness among nurses. Design A quantitative, cross-sectional study. Methods Nurses from a number of tertiary general hospitals in central China were surveyed and assessed using the Moral Distress Scale, the Nurse Moral Resilience Scale, and the nurse job embeddedness Scale from February to March 2023. The study was conducted in line with the 1964 Declaration of Helsinki. Ethical consideration All study procedures were approved by the Ethics Committee of Hunan Normal University (No. 2023-313). Findings Moral distress was positively correlated with moral resilience ( β = 0.525, p < 0.01) and negatively correlated job embeddedness ( β = −0.470, p < 0.01). Moral resilience partially mediated the relationship between moral distress with job embeddedness ( β = −0.087, p < 0.01). Discussion The findings reveal a relationship between moral distress, job embeddedness, and moral resilience among nurses. Conclusion Moral distress and moral resilience are important correlates of job embeddedness in nurses. Interventions to reduce moral distress and increase moral resilience may have potential benefits for improving nurses’ job embeddedness. It is recommended that clinical nursing administrators create a favorable ethical atmosphere, educate nurses about ethics, and increase nurses' moral resilience. (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: Why nurses remain in the profession is a complex question. However, strong values can be grounds for their remaining, meaning nurses evaluate the qualitative worth of different desires and distinguish between senses of what is a good life. Research question: The overall aim is to explore and argue the relevance of strong evaluations for remaining in the nursing profession. Research design: This theoretical article based on a hermeneutical approach introduces the concept strong evaluations as described by the Canadian philosopher (...) Charles Taylor and provides examples of nurses’ experiences in everyday nursing care drawn from a Norwegian empirical study. Participants and research context: Data collected in the original study consisted of qualitative interviews and qualitative follow-up interviews with 13 nurses. The research context was the primary and secondary somatic and psychiatric health service, inside as well as outside institutions. Ethical consideration: The article uses data from an original empirical study approved by the Norwegian Social Science Data Services. Information was given and consent obtained from the participants. Findings: Remaining in the nursing profession can be understood as revolving around being a strong evaluator. This has been concretized in issues of being aware of different incidents in life and having capacities as a nurse. Discussion: Why nurses remain is discussed in relation to how nurses have shaped themselves by reflecting on what is of significance in their life. However, being a strong evaluator cannot be seen as the casual condition for remaining. Conclusion: Remaining in the nursing profession is obviously not a contingent matter, rather it is a matter concerned with the qualitative worth of different desires and values. Nurses’ awareness of a life choice impacts on whether they remain or not. Consequently, nurses may need to articulate and reflect on their priorities for remaining. (shrink)