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)

Background: Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit. Research aims: The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality (...) of nursing family care and family wellbeing. Research design: A cross-sectional, correlational design was used. Participants and research context: Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States. Instruments: The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing. Data analysis: Hierarchical regression and mediation analysis were used to answer the study aims. Ethical considerations: The study was approved by the Institutional Review Board at the study site. Findings: In separate regression models, organizational resources for ethical conflict (β =.401, p =.006) and depersonalization (β = −.511, p =.006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (β =.341, 95% confidence interval (.015,.707)). Discussion: Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit. Conclusion: Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit. (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)

Background Moral distress appears when a healthcare professional is not able to carry out actions in accordance with their professional ethical standards. The Moral Distress Scale-Revised is the most widely used to assess levels of moral distress, but it is not validated in Spanish. The aim of the study is to validate the Spanish version of the Moral Distress Scale – utilised within a sample of Spanish healthcare professionals treating COVID–19 patients. Methods The original (english) and the portuguese and french (...) versions of the scale were translated into spanish by native or bilingual researchers and reviewed by an academic expert in ethics and moral philosophy as well as by a clinical expert. Research design: Descriptive cross-sectional study carried out using a self-reporting online survey. The data was collected between June- November 2020. A total of 661 professionals responded to the survey (N = 2873). Participants: healthcare professionals with more than two weeks of experience treating COVID–19 patients at the end of their life and working in the public sector of the Balearic Islands Health Service (Spain). Analyses included descriptive statistics, competitive confirmatory factor analysis, evidence on criterion-related validity and estimates of reliability. The study was approved by the Research Ethics Committee at the University of Balearic Islands. Results An unidimensional model in which a general factor of moral distress explained by 11 items of the Spanish version of the MDS–R scale was an adequate representation of the data: χ 2 (44) = 113.492 (p 0.001); Comparative Fit Index = 0.965; Root Mean Square Error of Approximation = 0.079[0.062,0.097]; and Standarized Root Mean-Square = 0.037. Evidence of reliability was excellent: Cronbach’s alpha = 0.886 and McDonald’s omega = 0.910. Moral distress was related to discipline, with nurses having statistically significant higher levels than physicians. Additionally, moral distress successfully predicted professional quality of life, with higher levels of moral distress being related to poorer quality of life. Conclusions The Spanish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by health professionals. This tool will be highly useful for managers and applicable to a variety of healthcare professionals and settings. (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 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)

Background: Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand. Objective: This study aims to describe the experience of moral distress and related factors among Thai nurses. Design: A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of (...) Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated. Participants: Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand. Ethical considerations: This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151. Results: A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress. Discussion: Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient’s and family’s religious perspective that ties into the concept of moral distress needs to be explored. Conclusions: Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context. (shrink)

This article proposes to identify risk factors for moral distress from the literature, validate them through expert analysis and provide the basis for a new tool to assess the risk of moral distress among nurses. Moral distress is related to the psychological, emotional and physiological aspects of nursing. It arises from constraints caused by various circumstances and can lead to significant negative consequences. A scoping review and validation through expert analysis were used. The research question guiding this study was as (...) follows: What is known about risk factors for moral distress in nursing? The research was conducted using multiple sources including electronic databases and lists of references from relevant literature. The final sample consisted of 38 studies. A validation analysis was conducted by experts during December 2014 and June 2015. To exclude a risk factor item, at least 80% of the experts had to agree with the exclusion. In total, 53 risk factors for moral distress were identified, reviewed by the experts and grouped to form a new instrument that may help to identify risk for moral distress and to address its consequences. (shrink)

BackgroundMoral distress is one of the most important problems that nurses face in their care of patients. Various studies have reported the frequency and severity of moral distress in nurses. However, to date, a comprehensive study that shows the results of these research across the world was not found, therefore due to the importance of this issue, its role in the health of nurses and patients, and the lack of general statistics about it worldwide, the present study was conducted to (...) determine the frequency and severity of moral distress in nurses through a systematic review and meta-analysis.MethodsIn this review study, searching national and international databases of SID, MagIran, IranMedex, IranDoc, Google Scholar, Embase, ScienceDirect, Scopus, CINHAL, PubMed, and Web of Science between 2005 and February 2020 were extracted. The random-effects model was used for analysis, and the heterogeneity of studies with the I2 index was investigated. Data were analyzed using Comprehensive Meta-Analysis.ResultsThe frequency of moral distress in 9 articles with a sample size of 1576 persons was 1.7 ± 0.5 from, in 13 articles with a sample size of 1870 persons, 3.07 ± 0.1 from, in 6 articles with a sample size of 1316 persons, 3.2 ± 0.29 from, in 18 articles with a sample size of 1959 persons, 4.6 ± 0.518 from and in 35 articles with a sample size of 3718 persons, 81.1 ± 4.6 from, and the severity of moral distress in 4 articles with a sample size of 1116 persons, 1.7 ± 0.37 from, in 5 articles with a sample size of 1282 persons, 2.6 ± 0.28 from, in 5 articles with a sample size of 944 persons, 3.9 ± 0.63 from and in 8 articles with a sample size of 901 persons was 82.3 ± 5.4.ConclusionThe results of this study showed that the frequency and severity of moral distress in nurses are high and are a serious problem in nurses. Therefore, policymakers in this field should consider its role in the health of nurses and patients. (shrink)

Background: While conscientious objection is a well-known phenomenon in normative and bioethical literature, there is a lack of evidence to support an understanding of what it is like for nurses to make a conscientious objection in clinical practice including the meaning this holds for them and the nursing profession. Research question: The question guiding this research was: what is the lived experience of conscientious objection for Registered Nurses in Ontario? Research design: Interpretive phenomenological methodology was used to gain an in-depth (...) understanding of what it means to be a nurse making a conscientious objection. Purposive sampling with in-depth interview methods was used to collect and then analyze data through an iterative process. Participants and research context: Eight nurse participants were interviewed from across practice settings in Ontario, Canada. Each participant was interviewed twice over 9 months. Ethical considerations: This study was conducted in accordance with Health Science Research Ethics Board approval and all participants gave consent. Findings: Six themes emerged from data analysis: encountering the problem, knowing oneself, taking a stand, alone and uncertain, caring for others, and perceptions of support. Discussion: This study offers an initial understanding of what it is like to be a nurse making a conscientious objection in clinical practice. Implications for nursing practice, education, policy, and further research are discussed. Conclusion: Addressing ethical issues in nursing practice is complex. The need for education across nursing, healthcare disciplines and socio-political sectors is essential to respond to nurses’ ethical concerns giving rise to objections. Conscience emerged as an informant to nurses’ conscientious objections. The need for morally inclusive environments and addressing challenging ethical questions as well as the concept of conscience are relevant to advancing nursing ethics and ethical nursing practice. (shrink)

Background: Moral distress and workplace bullying are important issues in the nursing workplace that appear to affect nurse’s burnout. Aim: To investigate the relationship between moral distress and burnout in Iranian nurses, as mediated by their perceptions of workplace bullying. Ethical considerations: The research was approved by the committee of ethics in research of the Urmia University of Medical Sciences. Method: This is a correlation study using a cross-sectional design with anonymous questionnaires as study instruments (i.e. Moral Distress Scale-Revised, Maslach (...) Burnout Inventory and The Negative Acts Questionnaire-Revised). Data were collected from 278 nurses from five teaching hospitals in Urmia, the capital of Western Azerbaijan, northwest of Iran. Structural equation modeling and bootstrapping procedures were employed to recognize the mediating role of their perceptions of workplace bullying. Results: The mean score of moral distress, burnout, and the Negative Acts Questionnaire-Revised Scale among the participants were 91.02 ± 35.26, 79.9 ± 18.27, and 45.4 ± 15.39, respectively. The results confirmed our hypothesized model. All the latent variables of study were significantly correlated in the predicted directions. The moral distress and bullying were significant predictors of burnout. Perception of bullying partially mediated the relationship between moral distress and burnout. The mediating role of the bullying suggests that moral distress increases burnout, directly and indirectly. Conclusion: Nursing administrators should be conscious of the role of moral distress and bullying in the nursing workplace in increasing burnout. (shrink)