Background: The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction. Aim: Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. Research design: A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. Ethical considerations: Ethical approval granted (...) by the Regional Research Ethics Committee in Western Norway (131421). Findings: Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. Discussion: By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority. Conclusion: Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms. (shrink)

Background: Moral sensitivity is the foremost prerequisite to ethical performance; a review of literature shows that nurses are sometimes not sensitive enough for a variety of reasons. Moral distress is a frequent phenomenon in nursing, which may result in paradoxes in care, dealing with patients and rendering high-quality care. This may, in turn, hinder the meeting of care objectives, thus affecting social healthcare standards. Research objective: The present research was conducted to determine the relationship between moral sensitivity and moral distress (...) of nurses in intensive care units. Research design: This study is a descriptive-correlation research. Lutzen’s moral sensitivity questionnaire and Corley Moral Distress Questionnaire were used to gather data. Participants and research context: A total of 153 qualified nurses working in the hospitals affiliated to Shahid Beheshti University of Medical Sciences were selected for this study. Subjects were selected by census method. Ethical considerations: After explaining the objectives of the study, all the participants completed and signed the written consent form. To conduct the study, permission was obtained from the selected hospitals. Findings: Nurses’ average moral sensitivity grade was 68.6 ± 7.8, which shows a moderate level of moral sensitivity. On the other hand, nurses also experienced a moderate level of moral distress (44.8 ± 16.6). Moreover, there was no meaningful statistical relationship between moral sensitivity and moral distress (p = 0.26). Discussion: Although the nurses’ moral sensitivity and moral distress were expected to be high in the intensive care units, it was moderate. This finding is consistent with the results of some studies and contradicts with others. Conclusion: As moral sensitivity is a crucial factor in care, it is suggested that necessary training be provided to develop moral sensitivity in nurses in education and practical environments. Furthermore, removing factors that contribute to moral distress may help decrease it in nurses. (shrink)

Background: Ethical conflicts in nursing have generally been studied in terms of temporal frequency and the degree of conflict. This study presents a new perspective for examining ethical conflict in terms of the degree of exposure to conflict and its typology. Objectives: The aim was to examine the level of exposure to ethical conflict for professional nurses in critical care units and to analyze the relation between this level and the types of ethical conflict and moral states. Research design: This (...) was a descriptive correlational study. Central and dispersion, normality tests, and analysis of variance were carried out. Participants and research context: A total of 203 nurses were from two third-level teaching hospitals in Spain. Both centers are part of the University of Barcelona Health Network. Participants filled out the Ethical Conflict in Nursing Questionnaire–Critical Care Version. Ethical considerations: This investigation received the approval of the ethical committees for clinical investigation of the two participating hospitals. Participants were informed of the authorship and aims of the study. Findings: The index of exposure to ethical conflict was [Formula: see text]. The situations involving analgesic treatment and end-of-life care were shown to be frequent sources of conflict. The types of ethical conflict and moral states generally arranged themselves from lesser to greater levels of index of exposure to ethical conflict. Discussion: The moderate level of exposure to ethical conflict was consistent with other international studies. However, the situations related with family are infrequent, and this presents differences with previous research. The results suggest that there is a logical relationship between types of conflict and levels of exposure to ethical conflict. Conclusion: The types of ethical conflict and moral states were related with the levels of exposure to ethical conflict. The new perspective was shown to be useful for analyzing the phenomenon of ethical conflict in the nurse. (shrink)

Background: Positioned at the frontlines of the battle against COVID-19 disease, nurses are at increased risk of contraction, yet as they feel obligated to provide care, they also experience ethical pressure. Research question and objectives: The study examined how Israeli nurses respond to ethical dilemmas and tension during the COVID-19 outbreak, and to what extent this is associated with their perceived risk and motivation to provide care? Research design: The study implemented a descriptive correlative study using a 53-section online questionnaire, (...) including 4 open-ended questions. Participants and research context: The questionnaire was complete by 231 registered and intern nurses after being posted on nurses’ Facebook and WhatsApp groups, and through snowball sampling. Ethical considerations: The research was pre-approved by the ethics committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa, Israel. Findings: In all, 68.8% of the respondents had received some form of training about COVID-19. Respondents positioned themselves at perceived high risk levels for contracting the virus. About one-third feared going to work because of potential contraction and due to feeling inadequately protected. While 40.9% were scared to care for COVID-19 patients, 74.7% did not believe they have the right to refuse to treat certain patients. When asked about defining an age limit for providing patients with scarce resources (such as ventilation machines) in cases of insufficient supplies, respondents stated that the maximum age in such scenarios should be 84 (standard deviation (SD = 19) – yet most respondents (81.4%) believed that every patient has the right to receive optimal treatment, regardless of their age and medical background. Discussion: Correlating with their strong commitment to care, nurses did not convey intention to leave the profession despite their stress, perceived risk, and feelings of insufficient support and protection at work. The nurses did not hold a utilitarian approach to resource allocation, thereby acknowledging the value of all people and their entitlement to care, regardless of optimal outcomes. Conclusion: While experiencing significant personal risk and emotional burden, nurses conveyed strong dedication to providing care, and did not regret working in the nursing profession, yet they did seek a supportive climate for their needs and ethical concerns. (shrink)

Background Ethical conflict is a problem with negative consequences, which can compromise the quality and ethical standards of the nursing profession and it is a source of stress for health care practitioners’, especially for nurses. Objectives The main aim of this study was to analyze Spanish critical care nurses’ level of exposure to ethical conflict and its association with sociodemographic, occupational, and COVID-19–related variables. Research Design, Participants, and Research context: This was a quantitative cross-sectional descriptive study conducted among 117 nurses (...) working in critical care units. Data collection tools were sociodemographic, occupational, and COVID-19–related questionnaires and previously validated Spanish version of Ethical Conflict in Nursing Questionnaire-Critical Care Version. Ethical Considerations We obtained permission from the Ethics Committee and participants' informed consent. Findings Data indicates a moderate level of exposure to ethical conflicts. The most frequent ethical conflicts were related to situations about "treatment and clinical procedures." The most intensity of ethical conflicts was related to situations about "treatment and clinical procedures" and "dynamics of the service and working environment." No statistical significance was identified between the socio-demographic variables and level of exposure to ethical conflicts. However, for critical care nurses working in ICU, nurses with perceived worked stress had a higher level of exposure to ethical conflicts. Likewise, critical care nurses whose family/friends were infected with COVID-19 had a higher level of exposure. Conclusions Critical care nurses experience a moderate level of exposure to ethical conflicts which is consistent with the results of previous studies. A deeper understanding of ethical conflicts in conflictive situations allows recognition of the situations that occur in everyday clinical practice, identification of the ethical conflicts, and facilitation of the nurses working in the challenging clinical situation. (shrink)

Background: Moral distress has been experienced by about 67% of critical care nurses which causes many complications such as job dissatisfaction, loss of capacity for caring, and turnover for nurses and poor quality of care for patients as well as health system. Objective: The purpose of this research was to provide a moral empowerment program to nursing directors, school of nursing, and the heads of hospitals to reduce moral distress in nurses and improve the quality of care. Methods: This research (...) was a randomized clinical trial conducted in two groups and three stages before, after 2 weeks, and 1 month after the intervention in order to evaluate the changes in moral distress of 60 nurses working in adults’ intensive care unit wards of Al-Zahra teaching hospital of Isfahan University of Medical Sciences. Data were collected using the standard Hamric’s Moral Distress Scale (2012) and analyzed using SPSS software version 22. Ethical considerations: This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran. Results: Results showed that in the three stages, there was no significant difference between the mean score of moral distress before (4.12 ± 2.70), 2 weeks after (4.23 ± 2.70), and 1 month after the intervention (4.04 ± 2.54) in the control group (p > 0.05), while in the experimental group, there was a significant difference between the three stages (p 0.05). However, this score significantly decreased 1 month after the intervention (2.64 ± 2.23; p < 0.05). Conclusion: In this research, it was observed that moral empowerment program has been effective in reducing the mean score of moral distress. Therefore, it is recommended that nursing managers and hospital directors implement empowerment program, in order to reduce the moral distress of nurses and improve the quality of care. (shrink)

BackgroundThe COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19.MethodsAn extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. ResultsThree (...) hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect, ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior.ConclusionLevels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care. (shrink)

Background: Physical restraint is among the commonly used methods for ensuring patient safety in intensive care units. However, nurses usually experience ethical dilemmas over using physical restraint because they need to weigh patient autonomy against patient safety. Aim: The aim of this study was to explore factors behind ethical dilemmas for critical care nurses over using physical restraint for patients. Design: This is a qualitative study using conventional content analysis approach, as suggested by Graneheim and Lundman, to analyze the data. (...) Methods: Seventeen critical care nurses were purposefully recruited from the four intensive care units in Tehran, Iran. Data were collected through in-depth semi-structured interviews and were concurrently analyzed through conventional content analysis as suggested by Graneheim and Lundman. Ethical consideration: This study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran with the code: IR.IUMS.REC.1397.795. Before interviews, participants were provided with explanations about the aim of the study, the confidentiality of the data, their freedom to participate, and the right to withdraw the study, and their free access to the study findings. Finally, their consents were obtained, and interviews were started. Results: Factors behind ethical dilemmas for critical care nurses over using physical restraint were categorized into three main categories, namely the outcomes of using physical restraint, the outcomes of not using physical restraint, and emotional distress for nurses. The outcomes of using physical restraint were categorized into the three subcategories of ensuring patient safety, physical damage to patients, and mental damage to the patient. The outcomes of not using physical restraint fell into two subcategories, namely the risks associated with not using physical restraint and legal problems for nurses. Finally, the two subcategories of the emotional distress for nurses main category were nurses’ negative feelings about restraint use and uncertainty over the decision on physical restraint use. Conclusion: Decision-making for restraint use is often associated with ethical dilemmas, because nurses need to weight the outcomes of its use against the outcomes of not using it and also consider patient safety and autonomy. Health authorities are recommended to develop clear evidence-based guidelines for restraint use and develop and implement educational and counseling programs for nurses on the principles of ethical nursing practice, patient rights, physical restraint guidelines and protocols, and management of emotional, ethical, and legal problems associated with physical restraint use. (shrink)

Little is known about the consequences of moral distress. The purpose of this study was to identify clinical situations that caused nurses to experience moral distress, to understand the consequences of those situations, and to determine whether nurses would change their practice based on their experiences. The investigation used a descriptive approach. Open-ended surveys were distributed to a convenience sample of 204 critical care nurses employed at a university medical center. The analysis of participants’ responses used an inductive approach and (...) a thematic analysis. Each line of the data was reviewed and coded, and the codes were collapsed into themes. Methodological rigor was established. Forty-nine nurses responded to the survey. The majority of nurses had experienced moral distress, and the majority of situations that caused nurses to experience moral distress were related to end of life. The nurses described negative consequences for themselves, patients, and families. (shrink)

One of the difficulties nurses experience in clinical practice in relation to ethical issues in connection with young oncology patients is moral distress. In this descriptive correlational study, the Moral Distress Scale-Paediatric Version (MDS-PV) was translated from the original language and tested on a conventional sample of nurses working in paediatric oncology and haematology wards, in six north paediatric hospitals of Italy. 13.7% of the total respondents claimed that they had changed unit or hospital due to moral distress. The items (...) with the highest mean intensity in the sample were almost all connected with medical and nursing competence and have considerably higher values than frequency. The instrument was found to be reliable. The results confirmed the validity of the MDS-PV (Cronbach’s alpha = 0.959). This study represents the first small-scale attempt to validate MDS-PV for use in paediatric oncology-ematology nurses in Italy. (shrink)

Background: Moral distress is one of intensive care unit nurses’ major problems, which may happen due to various reasons, and has several consequences. Due to various moral distress outcomes in intensive care unit nurses, and their impact on nurses’ personal and professional practice, recognizing moral distress is very important. Research objective: The aim of this study was to determine correlation between moral distress with burnout and anticipated turnover in intensive care unit nurses. Research design: This study is a descriptive-correlation research. (...) Participants and research context: A total of 159 intensive care unit nurses were selected from medical sciences universities in Iran. Data collection instruments included “demographic questionnaire,” “ICU Nurses’ Moral Distress Scale,” “Copenhagen Burnout Inventory” and “Hinshaw and Atwood Turnover Scale.” Data analysis was done by using SPSS19. Ethical considerations: Informed consent from samples and research approval was obtained from Shahid Beheshti Medical Sciences University Research Ethics Board in Tehran. Findings: The findings showed intensive care unit nurses’ moral distress and anticipated turnover was high, but burnout was moderate. The results revealed that there was a positive statistical correlation between intensive care unit nurses’ age, their work experience and the fraction of nurses’ number to number of intensive care unit beds with their moral distress and burnout. However, there were no correlation between gender, marriage status, educational degree and work shift and moral distress. Discussion: Some of the findings of this research are consistent with other studies and some of them are inconsistent. Conclusion: Similarly, moral distress with burnout and anticipated turnover did not have statistical correlation. However, a positive correlation was found between burnout and anticipated turnover. The results showed that increase in the recruitment of young nurses, and nursing personnel, and diminishing intensive care unit nurses’ moral distress, burnout and their turnover intention are essential. (shrink)

Introduction: Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored. Aim: The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire–Critical Care Version and, second, to analyse Portuguese critical care nurses’ level of exposure to ethical conflict and its (...) characteristics. Methods: A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016. Ethical Considerations: The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental. Findings: The Portuguese version of the Ethical Conflict Nursing Questionnaire–Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources. (shrink)

BackgroundEthical decision-making of nurses could affect patients’ recovery and also decrease medical costs. To make ethical decisions, ICU nurses experience complicated ethical conflicts. Considering the multi-dimensional process of ethical decision-making, the present study was conducted to describe the experiences of ICU nurses regarding ethical decision making.MethodThe present research is a qualitative study with conventional content analysis approach that was done in 2020. Fourteen ICU nurses were interviewed using a semi-structured in-depth interview method. The interviews were recorded, transcribed verbatim, and analyzed (...) using Granheim and Landman approach.ResultsBeing torn by inevitable moral dilemma was defined as the main category which contained the categories of conflict with professional self, feeling squeezed between self-authority and demands of others, and Surrounded by organizational limitations.ConclusionsResults of the present study showed that moral dilemma is a situation in which the nurses are forced to choose between two options based on their equipment and facilities. In these situations, the nurses would hesitate between their internal conflicts and confusion between choosing their own benefits and patients’ benefits. To prevent ethical challenges in decision making, it is necessary to educate healthcare team about ethical dilemmas and empower the personnel for encountering ethical challenges. (shrink)

Background: Nursing is a profession that has always been accompanied with common ethical concerns. There are some evidences which indicate that narrative writing on traumatic experiences may improve an individual’s emotional health. Objective: This study aimed to determine the effectiveness of narrative writing on moral distress of nurses working in intensive care unit. Research design: This study was a clinical trial with pre- and post-test design. The frequency and intensity of moral distress was measured by a valid and reliable questionnaire (...) (Corely) at baseline and after 8 weeks. The intervention group was asked to write about their deepest emotions and stressful experiences in the intensive care unit for 8 weeks. Participants and research context: Using consensus sampling, 120 nurses of intensive care unit and neonatal intensive care unit of the teaching hospitals (in Iran) were invited to and were randomly allocated into the intervention and control groups. Ethical considerations: Participation was voluntary, data were anonymized, and the confidentiality of the participating nurses and their institutions maintained. The ethical approval was obtained from an IRB or research ethics committee. Findings: In total, 106 nurses completed the trial consisting of 87.75% females. The mean work experience of nurses in the intervention and control groups was 7.21 ± 4.96 and 8.28 ± 5.45 years, respectively. Independent t-test showed no statistical difference neither in the intensity of moral distress ( P = 0.8), nor in its frequency ( P = 0.5) between the two groups. Discussion: As nurses constantly face ethical tensions, moral distress is a phenomenon that results from the different situations of critical care units. Their concern about receiving negative feedback from the managerial level may have influenced the outcome of the intervention. Conclusion: Narratives writing by the nurses showed no effect on reducing the intensity and frequency of moral distress. It seems that due to the intensity of moral distress in clinical settings, we need to test variety solutions to reduce the problem. (shrink)

Background: Ethical conflict is a barrier to decision-making process and is a problem derived from ethical responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this phenomenon. A deep study of the phenomenon can help prevent and treat it. Objectives: This study was aimed at determining the frequency, degree, level of exposure, and type of ethical conflict among nurses working in the intensive care units. Research design: This was a descriptive cross-sectional research. Participants and research (...) context: In total, 382 nurses working in the intensive care units in Iranian hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in Nursing Questionnaire-Critical Care Version (Persian version). Ethical considerations: This study was approved by the Medical Research Ethics Committee. Ethical considerations such as completing the informed consent form, ensuring confidentiality of information, and voluntary participation were observed. Findings: The results showed that the average level of exposure to ethical conflict was 164.39 ± 79.06. The most frequent conflict was related to “using resources despite believing in its futility,” with the frequency of at least once a week or a month (68.6%, n = 262). The most conflictive situation was violation of privacy (76.9%, n = 294). However, the level of exposure to ethical conflict according to the theoretical model followed was the situation of “working with incompetent staff.” The most frequently observed type of conflict was moral dilemma. Conclusion: The moderate level of exposure to ethical conflict was consistent with the results of previous studies. However, the frequency, degree, and type of ethical conflict were different compared to the results of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent ethical conflicts, and improve the nursing work environment. (shrink)

Moral distress is a fundamental problem in the nursing profession that affects nurses. Critical care nurses are more susceptible to this problem due to the nature of their work. Moral distress may, in turn, lead to several undesirable consequences. This study aimed to determine the relationship between moral distress and intention to leave the ward among critical care nurses. This descriptive-correlational study was conducted by census method on all eligible nurses who worked in Coronary Care Unit (CCU) and Intensive Care (...) Unit (ICU) of AhVaz hospitals, Iran. Data was collected by Corley’s moral distress questionnaire and a researcher-made questionnaire to investigate the intention to leave the ward. Questionnaires were completed through self-report and data were analyzed using a t-test and Pearson correlation coefficient. The results showed that there was a direct association between moral distress and intension to leave the ward in critical care nurses (P < 0.05). Also, the intensity of moral distress (P = 0.03) and the intention to leave the ward (P = 0.007) were significantly higher in ICU nurses. Given the high exposure of critical care nurses with moral distress and its association with leaving the ward, it seems that devising strategies to reduce or control moral distress and its negative consequences are necessary, particularly in ICU nurses. (shrink)