Background Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice. Research objective To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness. Ethical considerations The research was conducted in accordance (...) with the Declaration of Helsinki. Research design This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan Participants The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users. Findings The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive. Discussion The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants. Conclusion This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses’ moral distress, building ethics into decision-making. (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)

The concept of moral distress can be extended from clinical settings to larger environmental concerns affecting health care. Moral distress—a common experience in complex societies—arises when individuals have clear moral judgments about societal practices, but have difficulty in finding a venue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a necessary element for mitigating climate change. Because it is extremely (...) challenging to discuss these concerns in health care settings, those concerned about climate change and health care experience distress. This article outlines some philosophical concepts and perspectives that may be useful in mitigating this distress. (shrink)

Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral (...) doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves. (shrink)

Background Moral distress is a common challenge among professional nurses when caring for their patients, especially when they need to make rapid decisions. Therefore, leaving moral distress unconsidered may jeopardize patient quality of care, safety, and satisfaction. Aim To estimate moral distress among nurses. Methods This systematic review and meta-analysis conducted systematic search in Scopus, PubMed, ProQuest, ISI Web of Knowledge, and PsycInfo up to end of February 2022. Methodological quality of included studies was assessed using the Newcastle Ottawa checklist. (...) Data from included studies were pooled by meta-analysis with random effect model in STATA software version 14. The selected key measure was mean score of moral distress total score with its’ 95% Confidence Interval was reported. Subgroup analyses and meta-regressions were conducted to identify possible sources of heterogeneity and potentially influencing variables on moral distress. Funnel plots and Begg’s Tests were used to assess publication bias. The Jackknife method was used for sensitivity analysis. Ethical consideration The protocol of this project was registered in the PROSPERO database under decree code of CRD42021267773. Results Eighty-six manuscripts with 19,537 participants from 21 countries were included. The pooled estimated mean score of moral distress was 2.55 on a 0–10 scale [95% Confidence Interval: 2.27–2.84, I2: 98.4%, Tau2:0.94]. Publication bias and small study effect was ruled out. Moral distress significantly decreased in the COVID-19 pandemic versus before. Nurses working in developing countries experienced higher level of moral distress compared to their counterparts in developed countries. Nurses' workplace (e.g., hospital ward) was not linked to severity of moral disturbance. Conclusion The results of the study showed a low level of pooled estimated score for moral distress. Although the score of moral distress was not high, nurses working in developing countries reported higher levels of moral distress than those working in developed countries. Therefore, it is necessary that future studies focus on creating a supportive environment in hospitals and medical centers for nurses to reduce moral distress and improve healthcare. (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)

Aims: The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. Background: Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. Design: Systematic literature (...) review and narrative synthesis (November 2015–March 2016). Data sources: Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO® 1967–Present, CINAHL® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts. Review methods: Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. Results: In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. Conclusion: We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress. (shrink)

Unable to answer the call of our patients: mental health nurses’ experience of moral distress When health practitioners’ moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non‐professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of (...) moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses’ possible responses to intolerable situations. (shrink)

The aim of the present study was to investigate the association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. By means of the three scales Hospital Ethical Climate Survey, Moral Sensitivity Questionnaire and Work-Related Moral Stress, 49 participants’ experiences were assessed. The results of linear regression analysis indicated that moral stress was determined to a degree by the work place’s moral climate as well as by two aspects of the mental health staff’s moral sensitivity. The (...) nurses’ experience of ‘moral burden’ or ‘moral support’ increased or decreased their experience of moral stress. Their work-related moral stress was determined by the job-associated moral climate and two aspects of moral sensitivity. Our findings showed an association between three concepts: moral sensitivity, moral climate and moral stress. Despite being a small study, the findings seem relevant for future research leading to theory development and conceptual clarity. We suggest that more attention be given to methodological issues and developing designs that allow for comparative research in other disciplines, as well as in-depth knowledge of moral agency. Copyright © 2011 by SAGE Publications. (shrink)

There are few evidence-based interventions that have been developed that mitigate the negative effects of moral distress. Group debriefing is one approach that some clinical ethicists have adopted as a response. However, there is very little academic literature or empirical research that identifies best practices and approaches to debriefing as a response to moral distress. Our aim at the 2020 UnConference was to share our different approaches to debriefing with other clinical ethicists to identify best practices or guiding principles to (...) enhance our respective approaches and meet the needs of healthcare professionals. In this article we share an overview of our respective approaches, reflect on our discussion with other clinical ethicists and healthcare professionals, and propose foundations to move debriefing forward as an intervention to address moral distress in the field of clinical ethics. (shrink)

Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work (...) or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience. (shrink)

Much research is currently being conducted on health care practitioners' experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton's influential description of moral distress. I will identify and aim to resolve two sources of confusion about (...) moral distress: the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and the distinction drawn between moral dilemma and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both. (shrink)

Background: Nursing practice is complex, as nurses are challenged by increasingly intricate moral and ethical judgments. Inadequately studied in underrepresented groups in nursing, moral distress is a serious problem internationally for healthcare professionals with deleterious effects to patients, nurses, and organizations. Moral distress among nurses has been shown to contribute to decreased job satisfaction and increased turnover, withdrawal from patients, physical and psychological symptoms, and intent to leave current position or to leave the profession altogether. Research question: Do significant gender (...) differences exist in the moral distress scores of critical care nurses? Research design: This study utilized a quantitative, descriptive methodology to explore moral distress levels in a sample of critical care nurses to determine whether gender differences exist in their mean moral distress scores. Participants and research context: Participants ( n = 31) were critical care nurses from an American Internet nursing community who completed the Moral Distress Scale–Revised online over a 5-day period in July 2013. Ethical considerations: Institutional review board review approved the study, and accessing and completing the survey implied informed consent. Findings: The results revealed a statistically significant gender difference in the mean moral distress scores of participants. Females reported statistically significantly higher moral distress scores than did males. Overall, the moral distress scores for both groups were relatively low. Discussion: The findings of a gender difference have not previously been reported in the literature. However, other findings are consistent with previous studies on moral distress. Conclusion: Although the results of this study are not generalizable, they do suggest the need for continuing research on moral distress in underrepresented groups in nursing, including cultural and ethnic groups. (shrink)

Background: When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems. Research objective: The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers. Research design: This study is a descriptive cross-sectional (...) research. Researcher-made questionnaire was used to gather data. Participants and research context: A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census. Ethical considerations: Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained. Findings: The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010). Discussion: The midwives’ moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses. Conclusion: After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures. (shrink)

This study aimed to: (1) develop and evaluate the Moral Distress Scale for Psychiatric nurses (MDS-P); (2) use the MDS-P to examine the moral distress experienced by Japanese psychiatric nurses; and (3) explore the correlation between moral distress and burnout. A questionnaire on the intensity and frequency of moral distress items (the MDS-P: 15 items grouped into three factors), a burnout scale (Maslach Burnout Inventory — General Survey) and demographic questions were administered to 391 Japanese psychiatric nurses in 2007—2008. These (...) nurses experienced relatively low levels of moral distress despite the fact that they were commonly confronted by morally distressing situations. All the circumstances in which the participants experienced moral distress were included in the ‘low staffing’ factor, which reflects the characteristics of Japanese psychiatric care. The frequency score of the low staffing factor was a significant predictor of burnout. (shrink)

Background: Since moral distress affects psychological aspects of psychiatric nurses, it is an important theme. Previous studies showed relationships between moral distress and job satisfaction; however, there are few studies which investigate relationships between moral distress and other effective variables and then we highlighted relationships among these variables. Objective: This study aimed to (1) examine relationships among moral distress, sense of coherence, mental health, and job satisfaction and (2) clarify the most predictive variable to job satisfaction. Research design: This study (...) is a cross-sectional study. Participants were 130 psychiatric nurses in a hospital in Japan. They completed the Moral Distress Scale for Psychiatric nurses (Unethical conduct, Low staffing, and Acquiescence to patients’ rights violations), the sense of coherence scale (Comprehensibility, Manageability, and Meaning), the General Health Questionnaire, and the Job Satisfaction scale. Ethical consideration: This study was approved by the ethical board of St Mary’s College. Nurses participated voluntarily and were anonymous. Results: Results showed that subscales of the Moral Distress Scale for Psychiatric nurses negatively correlated to the sense of coherence and the Job Satisfaction. A multiple regression analysis showed that “Acquiescence to patients’ rights violations” of the Moral Distress Scale for Psychiatric nurses and “Meaning” of the sense of coherence influenced the Job Satisfaction much more than other variables. These two variables were correlated to job satisfaction scale, and other variables without them did not significantly correlate to job satisfaction scale. Discussion: These results suggest that moral distress negatively related to sense of coherence and job satisfaction, a subscale of the Moral Distress Scale for Psychiatric nurses and that of the sense of coherence affected the job satisfaction the most. Conclusion: Decreasing of acquiescence to patients’ rights violations and finding meaning in nursing may improve job satisfaction. (shrink)