Ethical awareness enables nurses to recognize the ethical implications of all practice actions, and is an important component of safe and high quality nursing care (Milliken 2016; Milliken and Grac...

An important and supposedly impactful form of clinical ethics support is moral case deliberation. Empirical evidence, however, is limited with regard to its actual impact. With this literature review, we aim to investigate the empirical evidence of MCD, thereby a) informing the practice, and b) providing a focus for further research on and development of MCD in healthcare settings. A systematic literature search was conducted in the electronic databases PubMed, CINAHL and Web of Science. Both the data collection and the (...) qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of our decisions. The qualitative analysis was supported by ATLAS.ti. Based on a qualitative analysis of 25 empirical papers, we identified four clusters of themes: 1) facilitators and barriers in the preparation and context of MCD, i.e., a safe and open atmosphere created by a facilitator, a concrete case, commitment of participants, a focus on the moral dimension, and a supportive organization; 2) changes that are brought about on a personal and inter-professional level, with regard to professional’s feelings of relief, relatedness and confidence; understanding of the perspectives of colleagues, one’s own perspective and the moral issue at stake; and awareness of the moral dimension of one’s work and awareness of the importance of reflection; 3) changes that are brought about in caring for patients and families; and 4) changes that are brought about on an organizational level. This review shows that MCD brings about changes in practice, mostly for the professional in inter-professional interactions. Most reported changes are considered positive, although challenges, frustrations and absence of change were also reported. Empirical evidence of a concrete impact on the quality of patient care is limited and is mostly based on self-reports. With patient-focused and methodologically sound qualitative research, the practice and the value of MCD in healthcare settings can be better understood, thus making a stronger case for this kind of ethics support. (shrink)

Although moral distress is now a well-recognized phenomenon among all of the healthcare professions, few evidence-based strategies have been published to address it. In morally distressing situations, the “presenting problem” may be a particular patient situation, but most often signals a deeper unit- or system-centered issue. This article describes one institution’s ongoing effort to address moral distress in its providers. We discuss the development and evaluation of the Moral Distress Consultation Service, an interprofessional, unit/system-oriented approach to addressing and ameliorating moral (...) distress. (shrink)

In their article “A Broader Understanding of Moral Distress,” Campbell, Ulrich, and Grady (2016) correctly assert that moral distress is well established in the nursing literature and is gaining at...

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)

Stephen Campbell, Connie Ulrich, and Christine Grady argue that we need to a broader understanding of moral distress – broader, that is, than the one commonly used within nursing-ethics and, more recently, healthcare ethics in general. On their proposed definition, moral distress is any self-directed negative attitude we might have in response to viewing ourselves as participating in a morally undesirable situation. While being in general agreement with much of what Campbell et al. say, I make two suggestions. First, in (...) order to distinguish moral distress that is specifically related to the roles and responsibilities of healthcare-workers from other kinds of moral distress, it would be useful for the broadened definition to contain an explicit reference to the distinctive situation and challenges faced by healthcare-workers. Second, whereas Campbell et al. write in a manner that suggests that there is very little that is positive or redeeming about moral distress, we should also ask if there is anything morally good about such distress. I suggest that the disposition to respond with moral distress to situations that call for it can plausibly be seen as a virtue on the part of healthcare-workers. The moral value of responses of appropriate moral distress is positive (because it is a display of virtue on the part of the healthcare-worker), whereas the state of affairs that moral distress is called for is bad and regrettable. (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)

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)

South African research ethics committees (RECs) faced significant challenges during the COVID-19 pandemic. Research ethics committees needed to find a balance between careful consideration of scientific validity and ethical merit of protocols, and review with the urgency normally associated with public health emergency research. We aimed to explore the views of South African RECs on their pandemic preparedness and response during COVID-19. We conducted in-depth interviews with 21 participants from RECs that were actively involved in the review of COVID-19 related (...) research, at seven academic institutions across South Africa. Interviews were conducted remotely using an in-depth interview guide that included questions regarding REC preparedness and response to COVID-19. Interviews were conducted until data saturation, and audio-recordings were transcribed verbatim and coded. An inductive approach to thematic analysis was used to organise data into themes and sub-themes. This study focused on three main themes: coping during COVID-19, building REC capacity during pandemic times and a consistently cautious approach to mutual recognition of REC reviews. Despite an initial sense of unpreparedness, RECs were able to adapt and maintain careful ethical oversight of both COVID and non-COVID research, and the rigour of REC reviews. Several important lessons for preparedness and response to future pandemics were identified, including heightened awareness of publication, funding and political pressures, the importance of regular training for RECs and researchers, and strategies to enhance moral resilience of REC members. Incremental steps are needed to build trust and authentic partnerships among RECs in inter-pandemic times, to facilitate collaboration during future public health emergencies. (shrink)

Background Encounters of moral distress have long-term consequences on healthcare workers’ physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited. Research Objective The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic (...) medical center. Participants & Research Context Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim. Research Design Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine’s National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings. Ethical Considerations Ethics approval was obtained from the university and medical center institutional review boards. Findings Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities. Conclusion Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being. (shrink)

In response to the case study of Mr. Rivers, we will speak to three critical elements for an ethics consultant to address when a consult is requested due to moral distress. First, discern if the re...

Mr. Rivers’ case offers an example of how a caregiver may perceive the concept of moral distress. The nurse is experiencing what is described as moral distress at the prospect of participating in C...

The unique role of the nurse ethicist in the clinical setting is one meant to enhance the ethical capacity of nurses, and front-line healthcare providers. As a nurse ethicist, it is also my goal to enhance the ethical climate of each individual work area, patient care unit, and the broader institution by encouraging ethical conversations, navigating ethical dilemmas, and seeking creative solutions to minimize moral distress and burnout. To provide preventive ethics support and education, I began regularly visiting patient care (...) areas for ethics rounds, which I affectionately named “E-walks” (for Ethics Walks). I will discuss and reflect upon the lessons that have emerged as three key components of “E-Walks”: Recognition, Solidarity and Dialogue. These themes will speak to the unique presence and availability of a nurse ethicist as a valuable resource to front-line healthcare providers who face ethical dilemmas and morally concerning cases. I will go on to argue and demonstrate that my role as the nurse ethicist lies at the intersection of bioethics and the theoretical framework of the “ethic of care,” which is focused on building, creating, and sustaining caring interprofessional relationships through the work of ethics, nursing, and education. (shrink)