In recent years, the phenomenon of moral distress has been critically examined—and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re‐examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral (...) action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re‐centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of ‘narrow' moral distress and the value of re‐considering moral distress. Finally, we provide an action‐oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency. (shrink)

Background Moral courage means courage to act according to individual’s own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower. Objective To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care. Research design Was a descriptive-correlational study using a questionnaire, containing Nurses Moral Courage Scale©, a video vignette of (...) the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives. Participants and research context Nurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses’ Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette. Ethical considerations Good scientific inquiry guidelines were followed. Permission to use the Nurses’ Moral Courage Scale© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses’ Association. Findings The mean value of potential whistle-blowers’ moral courage on a Visual Analogue Scale (0–10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers’ moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables. Discussion and conclusion In health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing. (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)

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

Background: While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings. Research objective: The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker. Research design and participants: (...) A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials. Ethical considerations: After receiving ethics approval, signed informed consent was obtained from participants before data collection. Results: Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage. Discussion: The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women. Conclusion: Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice. (shrink)

Neoliberalism has ushered in a rise in managerialism, technocracy and bureaucratisation in residential child care where economy, efficiency, and effectiveness have been prioritised over the moral imperative to care. One implication has been the commodification of children who are traded in a culture of procurement and commissioning compounded by a climate of austerity, and where moral regulation has been replaced by contractual regulation. The impact of this upon the care that children receive has raised concern. The impact upon frontline carers (...) of intractable moral challenges which this climate presents in their role of caring each day is less well understood. The naming of an experience can provide an important starting place to understanding and challenging it. This article draws upon the phenomenon of ‘moral distress’, which is well documented in the medical field, and considers the transferability of this phenomenon from nursing to residential child care. It proposes that moral distress discourse may provide a language to residential child care workers through which their experience of the betrayal of the moral fabric of their work may be articulated. (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 describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers’ moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in (...) the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised, were lower for respondents in all categories, and on three specific items. Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS, a statistically significant increase in both code status changes DNR, and in-hospital death, with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients. (shrink)

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

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

Introduction: During their education process, nursing undergraduates experience ethical conflicts and dilemmas that can lead to moral distress. Moral distress can deprive the undergraduates of their working potential and may cause physical and mental health problems. Objective: We investigated the experiences of the undergraduates in order to identify the existence of moral distress caused by ethical conflict and dilemmas experienced during their nursing education. Ethical considerations: This study was designed according to the principles of research with human beings and was (...) approved by the Human Research Ethics Committee. Method: A qualitative multiple-case study. Two federal higher education institutions were surveyed, from which 58 undergraduates in nursing participated in the study. The undergraduates were undergoing their professional training. The data were collected through focus groups and were submitted to thematic content analysis, with the resources of the ATLAS TI 7.0 software. Results: Moral distress in undergraduates is a reality and was identified in three axes of analysis: (1) moral distress is experienced by undergraduates in the reality of healthcare services, (2) the teacher as a source of moral distress, and (3) moral distress as a positive experience. Conclusion: The undergraduates in nursing manifest moral distress in different stages of their education, particularly during their professional training. The academic community should reflect and seek solutions for the reality of moral distress in undergraduates. (shrink)

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

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

Moral resilience is an emerging concept that has not been fully acknowledged. The aim of this study is to explain lived experiences of moral resilience in intensive care units nurses. This is a qualitative study with a content analysis approach guided by the method of Elo and Kyngäs and based on the theoretical framework of Defilippis et al. Data were collected through 17 in‐depth, individual, and semi‐structured interviews with 17 nurses, who were selected by purposeful sampling. The results of the (...) present study support the theory of Defilippis et al. while adding another category to it. Three categories of self‐awareness, harmonized connection, and moral well‐being, which are consistent with the result of Defilippis et al. were extracted deductively, while the category of moral agency was also extracted inductively from the data. The explanatory theory resulting from Defilippis et al.'s study can be used as a guide to cultivate and improve the moral resilience of nurses working in intensive care units. Moral resilience is fostered in nurses by nurturing and improving their capacities, such as self‐awareness, self‐efficacy, self‐confidence, and self‐reflection. These traits can help maintain and promote moral agency while establishing harmonized connections. Acquiring moral resilience skills can lead to positive outcomes and reduced moral distress. (shrink)

Background Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience. Aim The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil. Research design The research design is the qualitative study with discursive textual analysis. Participants (...) and research context : 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions. Ethical considerations The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity. Findings Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation. Conclusion From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience. (shrink)

Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We (...) reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation. (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)

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)

Delirium, a common syndrome in terminally ill people, presents specific challenges to a good death in end‐of‐life care. This paper examines the relational engagement between hospice nurses and their patients in a context of end‐of‐life delirium. Ethnographic fieldwork spanning 15 months was conducted at a freestanding residential hospice in eastern Canada. A shared value system was apparent within the nursing community of hospice; patients’ comfort and dignity were deemed most at stake and therefore commanded nurses’ primary attention. This overarching commitment (...) to comfort and dignity shaped all of nursing practice in this hospice, including practices related to end‐of‐life delirium. The findings of this study elaborate the ways in which hospice nurses interpreted and responded to the discomfort of their patients in delirium, as well as the efforts they made to understand their patients’ subjective experiences and to connect with them in supportive ways. In addition to what is already known about clinical assessment and treatment of delirium in palliative care settings, the findings of this study offer points of reflection for nurses anywhere who are contending with the relational challenges that delirium presents in end‐of‐life care. (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)

Background: Moral courage is required at all levels of nursing. However, there is a need for development of instruments to measure nurses’ moral courage. Objectives: The objective of this study is to develop a scale to measure nurses’ self-assessed moral courage, to evaluate the scale’s psychometric properties, and to briefly describe the current level of nurses’ self-assessed moral courage and associated socio-demographic factors. Research design: In this methodological study, non-experimental, cross-sectional exploratory design was applied. The data were collected using Nurses’ (...) Moral Courage Scale and analysed statistically. Participants and research context: The data were collected from a convenience sample of 482 nurses from four different clinical fields in a major university hospital in Finland for the final testing of the scale. The pilot comprised a convenience sample of 129 nurses. Ethical considerations: The study followed good scientific inquiry guidelines. Ethical approval was obtained from the university ethics committee and permission to conduct the study from the participating hospital. Findings: Psychometric evaluation showed that the 4-sub-scale, 21-item Nurses’ Moral Courage Scale demonstrates good reliability and validity at its current state of development showing a good level of internal consistency for a new scale, the internal consistency values ranging from 0.73 to 0.82 for sub-scales and 0.93 for the total scale, thus well exceeding the recommended Cronbach’s alpha value of >0.7. Principal component analysis and confirmatory factor analysis supported the theoretical construct of Nurses’ Moral Courage Scale. Face validity and expert panel assessments markedly contributed to the relevance of items in establishing content validity. Discussion and conclusion: Nurses’ Moral Courage Scale provides a new generic instrument intended for measuring nurses’ self-assessed moral courage. Recognizing the importance of moral courage as a part of nurses’ moral competence and its assessment offers possibilities to develop interventions and educational programs for enhancement of moral courage. Research should focus on further validation measures of Nurses’ Moral Courage Scale in international contexts. (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)

BackgroundHealth care professionals face a number of problems during crises, such as the COVID-19. Studies addressed the prevalence of moral injury among healthcare professionals during the COVID-19 outbreak. Lack of a valid standard of moral injury among health care professionals is one of the factors that has made it difficult to identify and treat this complication. This study aimed to evaluate the psychometric properties of the Moral Injury Symptoms Scale-Health Care Professionals among health care professionals in Iran.MethodsThis study was conducted (...) to evaluate the validity and reliability of the MISS-HP. The sample included 455 healthcare professionals working in four teaching hospitals in Kerman, who were in direct contact with patients. In this study, face validity, content validity, construct validity, and internal reliability of the MISS-HP were evaluated. Demographic information questionnaire, the Moral Injury Symptoms Scale-HealthCare Professionals, General Health Questionnaire, and Impact of Event Scale were administered to study participants.ResultsThe MISS-HP was evaluated using translation-back translation technique. The content validity index of the items and the scale were 0.9 and 0.99, respectively. Exploratory factor analysis showed a three-factor structure in the MISS-HP that explained 57.49% of the variance. Confirmatory factor analysis indices were acceptable. The cut-off point of the questionnaire was 36.5. There was a positive and moderate correlation between the Persian version of MISS-HP, GHQ, and IES-R. The Cronbach’s alpha coefficient of the Persian version of MISS-HP was 0.70.ConclusionThis study found that the MISS-HP is a concise, comprehensive, valid and reliable scale for assessing moral injury among health care professionals in clinical or research settings. This scale will be helpful for managers and researchers to identify and plan health policies and improve the psychological state of health care professionals. (shrink)

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

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

Background: Moral distress is an increasingly documented problem in nursing and might foster nurses’ intention to leave their workplace. It has been studied in different settings, but no specific research has been conducted in Italian correctional facilities. A recent Italian study produced a preliminary validation of the Moral Distress Scale for Correctional Nurses, which needs to be completed. Objectives: To investigate the level of moral distress of nurses working in the Italian correctional setting, by completing the validation process of the (...) Moral Distress Scale for Correctional Nurses. Methodology: Multicenter questionnaire survey. All correctional nurses (461) affiliated with the Italian Society of Medicine and Penitentiary Health (also called “Simspe-onlus”) were invited to participate and 238 responded. The survey was conducted between April and November 2017 through SurveyMonkey®. Analysis of covariance was conducted to investigate the relationship between moral distress and the other variables under study. Exploratory factor analysis was conducted on the scale to confirm its dimensions. Ethical considerations: The study was approved by the Italian Society of Medicine and Penitentiary Health (Simspe-onlus). The questionnaire included informed consent, pursuant to the law in force. The software could not accept questionnaires without explicit consent. Data were analyzed anonymously. Findings: The median score was 46.5, indicating moderate moral distress. The only variable affecting moral distress was work experience in correctional facilities. Longer experience was correlated to higher levels of moral distress and intention to leave. Incompetent colleagues and short staffing were related to higher levels of moral distress. The scale confirmed the one-dimensional structure suggested by the original authors. Discussion: This is the first study investigating moral distress among Correctional Nurses. The prison context is a high-risk environment for nurses, increasing the intention to leave the workplace. Conclusion: Corrective and protective measures, such as specific education, are needed to prevent moral distress development and to reduce nurses’ shortage in this area. (shrink)