Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare (...) context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration. (shrink)

The experience of ‘moral distress’ is an increasing focal point of contemporary medical and bioethics literature, yet it has received little attention in discussions intersecting with ethical theory. This is unfortunate, as it seems that the peculiar phenomenon may well help us to better understand a number of issues bearing both practical and theoretical significance. In this article, I provide a robust psychological profile of moral distress in order to shed a newfound light upon the longstanding problem of ‘dirty hands’. (...) I argue that moral distress offers evidence of the existence of dirty hands situations. By examining moral distress and its relationship to cases of dirty hands, it appears that few of us are completely immune to susceptibility to these sorts of troubling experiences. With this concern in mind, I provide various recommendations to help alleviate our morally distressing personal and professional lives. (shrink)

Moral distress (MD), the suffering experienced by professionals due to their restricted moral agency, has become a popular subject of study in the fields of social work and health care. Many of the existing measures of MD are targeted at certain professionals, such as health care workers, and are thus restricted to such contexts. This has challenged the conceptual development and empirical examination of MD as a phenomenon occurring across diverse professional groups in different work settings. This study introduces a (...) general measure of MD, the Moral Distress Instrument (MDI). It is not bound to specific professional contexts, and it aims to enable comparative and cross-disciplinary analyses of MD. The MDI consists of seven items that capture different forms of constrained moral agency and follow-up items measuring the level of distress related to these experiences. The reliability and validity of the MDI is investigated, and its distinctiveness from and associations with burnout are studied among a sample of Finnish social workers (n = 367). The MDI was shown to be a reliable and valid measure among the sample. The measures of MD and burnout were shown to tap separate constructs, although these experiences were strongly associated with each other. (shrink)

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom (...) and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. (shrink)

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care (...) professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates. (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)

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 Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses’ experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. Research aim To analyze frontline U.S. nurses’ experiences of ethics during the COVID-19 pandemic. Research design Qualitative analysis using a directed content (...) methodology. Participants and research context The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. Ethical considerations Participant privacy and data confidentiality were addressed. Findings Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. Discussion This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. Conclusions Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available. (shrink)