Background Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time. Aim The aim of this study was to translate the MDT and adapt it to the Swedish cultural context. Research design The first part of this study concerns the translation of MDT to the (...) Swedish context, and the second part the psychometric testing of the Swedish version. Participants and research context 89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch’s ANOVA, Games–Howell post-hoc test and Pearson’s correlation analysis were done. Ethical considerations The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration. Results The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress. Conclusion The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context. (shrink)

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search (...) and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact. (shrink)

Technological advances in veterinary medicine have produced considerable progress in the diagnosis and treatment of numerous diseases in animals. At the same time, veterinarians, veterinary technicians, and owners of animals face increasingly complex situations that raise questions about goals of care and correct or reasonable courses of action. These dilemmas are frequently controversial and can generate conflicts between clients and health care providers. In many ways they resemble the ethical challenges confronted by human medicine and that spawned the creation of (...) clinical ethics committees as a mechanism to analyze, discuss, and resolve disagreements. The staff of the North Carolina State University Veterinary Hospital, a specialty academic teaching institution, wanted to investigate whether similar success could be achieved in the tertiary care veterinary setting. We discuss the background and rationale for this method, as well as the approach that was taken to create a clinical ethics committee. (shrink)

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic’s trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach (...) to develop a moral distress intervention—proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness. (shrink)

Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, (...) and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well‐understood in terms of what Bernard Williams calls “agent‐regret.” We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience. (shrink)

Backgrounds Moral distress significantly affects pediatric ICU nurses, leading to nurse burnout, increased turnover and reducing patient care quality. Despite its importance, there’s a notable gap in knowledge on how to manage it effectively. Aims This review aimed to systematically identify and analyze coping strategies and interventions targeting moral distress among pediatric nurses in ICU, uncovering research gap and future studies directions. Methods A scoping review was conducted followed framework by Levac, Colquhoun, and O'Brien and Arksey and O'Malley. Searches were (...) performed in 11 electrical databases, like PubMed and China Biology Medicine disc, within a timeframe of the database construction to November 2023, and performed literature screening and data extraction. Results Sixteen articles were ultimately included. Coping strategies adopted by pediatric ICUs nurses can be categorized into adaptive and maladaptive strategies, with the latter including passive acceptance, taking leave, and drinking, while the former involve pursuing interests outside of work, reflection and philosophizing, and communication. Nine articles described and evaluated the effectiveness of interventions for moral distress, categorizing them into individual and institutional levels. Individual-level interventions include Interprofessional Perspective-Taking, the PICU Resiliency Bundle, Ethics Education/Skills, and the Center for Caring. Institutional-level interventions encompasses Comprehensive Care Round, Goals of Care Conversations, Pediatric Ethics and Communication Excellence Rounds, Nursing Ethics Council, and Medical Ethical Decision-Making, though not all were effective in alleviating moral distress. Conclusions Nurses often use self-adjustment strategies for moral distress, institutional ethical support focusing on enhancing nurses’ moral resilience, promoting reflective thinking and improving communication remains crucial. Various interventions for moral distress are currently available, but nurse engagement is low and their effectiveness remained to be verified. Future studies should explore what aids or hinders these interventions. There’s also a need for large, multicenter trials and ongoing evaluations to create effective support systems for pediatric ICU nurses. (shrink)

Research question/aim/objectives Providing care for hospitalized children causes moral distress to nurses. Employee participation in discovering and solving the everyday problems of the workplace is one of the ways to hear the voices of nurses. This study aimed to evaluate the effect of participatory management programs on perceived organizational support and moral distress in pediatric nurses. Research design A quasi-experimental study. Participants and research context The present study was conducted on 114 pediatric nurses in Iran. Data were collected using the (...) Perceived Organizational Support Scale and the Moral Distress Scale of nurses. The intervention included implementing a participatory management program in three treatment departments that were randomly selected and it lasted 4 months. Participatory management was at the level of problem-solving with a focus on investigating, solving, and correcting issues and problems of work shifts and departments concerning the physical environment, equipment of the department, improvement of work processes, and team cooperation. In the control group, ordinary organizational approaches to problem-solving were used. Ethical considerations This study was approved by the Ethics Committee of Mashhad School of Nursing and Midwifery. Informed consent was obtained from the study participants. Findings/results Based on the results, both groups were homogenous before the intervention in terms of moral distress and perceived organizational support. The results showed that the moral distress mean scores in the intervention group decreased from 1.45 (0.52) to 1.03 (0.37) after the intervention. Also, the score of the perceived organizational support was 2.12 (1.2) increased after the intervention to 2.68 (1.10) in the intervention group. Conclusions It was found that the participation of nurses in the problem-solving process to solve daily workplace issues can be effective in increasing their perceived organizational support and reducing their moral distress. (shrink)

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe primary (...) objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to (...) measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC. (shrink)

Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, (...) I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution. (shrink)

Background: Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed. Objective: To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation. Methods: A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. (...) The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale. Results: Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment. Conclusions: Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness. (shrink)

Background Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as (...) job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. Objectives We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. Research design An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. Participants Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. Research context This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. Ethical considerations The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. Findings Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. Discussion Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. Conclusion This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice. (shrink)

BackgroundCommentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units. Our aim was twofold: to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and determine the association between the ethical climate, moral distress, and intention to leave.MethodsWe performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a (...) large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire and the Measure of Moral Distress for Healthcare Professionals tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.ResultsNurses perceived the ethical climate for decision-making as less favorable than physicians. They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units and also demonstrated lower moral distress scores and lower “intention to leave” scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated ; moral distress and "intention to leave" was positively correlated ; and ethical climate and “intention to leave” were negatively correlated.ConclusionsSignificant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care. (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)

Background There is continued need for enhanced medical ethics education across the United States. In an effort to guide medical ethics education reform, we report the first interprofessional survey of a cohort of graduate medical, nursing and allied health professional students that examined perceived student need for more formalized medical ethics education and assessed preferences for teaching methods in a graduate level medical ethics curriculum. Methods In January 2018, following the successful implementation of a peer-led, grassroots medical ethics curriculum, student (...) leaders under faculty guidance conducted a cross-sectional survey with 562 of 1357 responses received among students enrolled in the School of Medicine, College of Nursing, Doctor of Physical Therapy and BS/ MD Professional Scholars programs at The Medical College of Georgia at Augusta University. An in person or web-based questionnaire was designed to measure perceived need for a more in-depth medical ethics curriculum. Results The majority of respondents were female, white and mid-20s in age. Almost half of respondents reported no prior medical ethics exposure or training in their previous educational experience, while 60% of students across all degree programs reported an interest in more medical ethics education and 92% noted that an understanding of medical ethics was important to their future career. Over a quarter of students were interested in pursuing graduate-level training in medical ethics, with case-based discussions, small group peer settings and ethics guest lectures being the most desired teaching methods. Conclusions The future physician, nursing and physical therapist workforce in our medical community demonstrated an unmet need and strong interest for more formal medical ethics education within their current coursework. Grassroots student-driven curricular development and leadership in medical ethics can positively impact medical education. Subsequent integration of interprofessional training in medical ethics may serve as a vital curricular approach to improving the training of ethically competent healthcare professionals and overcoming the current hierarchical clinical silos. (shrink)

Background No previous study has provided evidence for the scope and frequency of ethical dilemmas for paediatric nurses. It is essential to understand this to optimise patient care and tailor ethics support for nurses. Research aim The aim of this study was to explore the scope of nurses’ ethical dilemmas in a paediatric hospital and their engagement with the hospital clinical ethics service. Research design This study used a cross-sectional survey design. Participants and research context Paediatric nursing staff in a (...) tertiary paediatric centre in Australia completed an online survey asking about their exposure to a range of ethical dilemmas and their knowledge of the clinical ethics service. Analysis used descriptive and inferential statistics. Ethical considerations Ethical approval was granted from the hospital research committee. The survey was anonymous, and no identifying details of participants were collected. Results Paediatric nurses experienced a wide range of ethical dilemmas frequently, both in the intensive care and general areas. Knowledge and use of the clinical ethics service was poor and the most frequent challenge for nurses in managing dilemmas was feeling powerless. Conclusion There is a need to recognise the moral burden of ethical dilemmas for paediatric nurses in order to foster ethical sensitivity, and to provide adequate support to improve care and mitigate nursing moral distress. (shrink)

Moral distress is prevalent within the neonatal intensive care unit (NICU) and can negatively affect clinicians. Studies have evaluated the causes of moral distress and interventions to mitigate it...

Background: Moral distress is a very common experience in the nursing profession, and it is one of the main reasons for job dissatisfaction, burnout, and quitting among nurses. For instance, morally difficult situations in taking care of child patients who are severely ill may lead to moral distress for nurses. However, most of the studies about moral distress have been conducted on nurses of special wards and adult medical centers with much focus on developed countries. Subsequently, little has been researched (...) on this topic among nurses in other nations such as Iran, and most certainly, there has been hardly any such research involving Iranian pediatric nurses. Aim/objectives: This study was conducted to evaluate moral distress among nurses in selected pediatric hospitals in Tehran, Iran. Research design: This cross-sectional study was conducted on eligible nurses who were selected through proportional stratified sampling and who completed demographic characteristics and the pediatric version of Moral Distress Scale-Revised questionnaires. Data were analyzed using descriptive statistics, t test, one-way analysis of variance, and Pearson correlation coefficient. Participants and research context: In total, 195 pediatric nurses working at three selected children’s specialized university hospitals in Tehran participated in this study. Ethical considerations: This study was evaluated and approved by the institutional review board of Tehran University of Medical Sciences. Findings: The mean and standard deviation of total score of moral distress was 106.41 ± 61.64 within a range of 10–257. Also, the difference between the mean score of moral distress of the group who had not quitted their position and those who have quit in the past was statistically significant (p = 0.043). The situation that was associated with the highest moral distress was “observing medical students performing painful procedures on patients just to gain some skill.” Total score of moral distress was significantly higher among male nurses (p = 0.014), while nurses with a master’s degree experienced just a higher intensity of moral distress compared to those who had a bachelor’s degree (p = 0.006). Conclusion: Since many pediatric nurses clearly face moral distress while taking care of children, it is necessary to consider measures for preventing or decreasing situations that would lead to this distress. (shrink)

This article argues that while the presence and influence of “futility” as a concept in medical decision-making has declined over the past decade, medicine is seeing the rise of a new concept with similar features: suffering. Like futility, suffering may appear to have a consistent meaning, but in actuality, the concept is colloquially invoked to refer to very different experiences. Like “futility,” claims of patient “suffering” have been used (perhaps sometimes consciously, but most often unconsciously) to smuggle value judgments about (...) quality of life into decision-making. And like “futility,” it would behoove us to recognize the need for new, clearer terminology. This article will focus specifically on secondhand claims of patient suffering in pediatrics, but the conclusions could be similarly applied to medical decisions for adults being made by surrogate decision-makers. While I will argue that suffering, like futility, is not sufficient wholesale justification for making unilateral treatment decisions, I will also argue that claims of patient suffering cannot be ignored, and that they almost always deserve some kind of response. In the final section, I offer practical suggestions for how to respond to claims of patient suffering. (shrink)