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Moral Distress, Moral Residue, and the Crescendo Effect

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... Jameton's definition describes moral distress in psychological-emotional-physiological terms and is linked to the presence of constraint on nurses' moral agency (McCarthy and Gastmans, 2014). According to Epstein and Hamric (2009) the intensity of the experience of moral distress increases to a point and then decreases as the acute phase of the moral distress situation passesthe crescendo of moral distress. However, the feelings and personal discord from the moral distressing situation continue after the situation is over and this residual distress acts as a new baseline from which the next crescendo of moral distress builds (Epstein and Hamric, 2009). ...
... According to Epstein and Hamric (2009) the intensity of the experience of moral distress increases to a point and then decreases as the acute phase of the moral distress situation passesthe crescendo of moral distress. However, the feelings and personal discord from the moral distressing situation continue after the situation is over and this residual distress acts as a new baseline from which the next crescendo of moral distress builds (Epstein and Hamric, 2009). This might cause damage over time, especially when the person is repeatedly exposed to moral distressing situations (Epstein and Hamric, 2009;McCarthy and Gastmans, 2014). ...
... However, the feelings and personal discord from the moral distressing situation continue after the situation is over and this residual distress acts as a new baseline from which the next crescendo of moral distress builds (Epstein and Hamric, 2009). This might cause damage over time, especially when the person is repeatedly exposed to moral distressing situations (Epstein and Hamric, 2009;McCarthy and Gastmans, 2014). ...
Objectives: To describe critical care nurses' perception of moral distress during the second year of the COVID-19 pandemic. Design/methods: A cross-sectional study involving a questionnaire was conducted. Participants responded to the Italian version of the Moral Distress Scale-Revised, which consists of 14 items divided in dimensions Futile care (three items), Ethical misconduct (five items), Deceptive communication (three items) and Poor teamwork (three items). For each item, participants were also invited to write about their experiences and participants' intention to leave a position now was measured by a dichotomous question. The data were analysed with descriptive statistics and qualitative content analysis. The study followed the checklist (CHERRIES) for reporting results of internet surveys. Setting: Critical care nurses (n = 71) working in Swedish adult intensive care units. Results: Critical care nurses experienced the intensity of moral distress as the highest when no one decided to withdraw ventilator support to a hopelessly ill person (Futile care), and when they had to assist another physician or nurse who provided incompetent care (Poor teamwork). Thirty-nine percent of critical care nurses were considering leaving their current position because of moral distress. Conclusions: During the COVID-19 pandemic, critical care nurses, due to their education and experience of intensive care nursing, assume tremendous responsibility for critically ill patients. Throughout, communication within the intensive care team seems to have a bearing on the degree of moral distress. Improvements in communication and teamwork are needed to reduce moral distress among critical care nurses.
... 323 While some studies indeed report higher moral distress with increasing years of experience, others did not, and suggested conditioning over time to the workplace environment or getting closer to retirement as possible explanations. 272,319,324 In a US-based survey in emergency medicine residents a burn-out prevalence rate of 76.1% was reported indicating that burn-out begins as early as during residency training. 325 Fifty-eight percent of the surveyed clinicians in our study reported that a resuscitation attempt which they perceived as inappropriate caused moral distress. ...
... 291 Typical external constraints are communication difficulties, inadequate staffing, hierarchies within the healthcare system, lack of collegial relationships, lack of administrative support, policies and priorities that conflict with care needs, and fear of litigation. 272 Some authors suggest not to put the emphasis on institutional constraints, but to broaden the definition of moral distress to include other reasons making it impossible to follow the right course of action, such as an error of judgement, self-doubt, lack of assertiveness, lack of understanding the full situation, or other circumstances beyond one's control. 272,343 These constraints inhibit dialogue about clinical problems clashing with professional obligations such as to reduce harm and avoid unnecessary suffering and to respect patient's dignity. ...
... 272 Some authors suggest not to put the emphasis on institutional constraints, but to broaden the definition of moral distress to include other reasons making it impossible to follow the right course of action, such as an error of judgement, self-doubt, lack of assertiveness, lack of understanding the full situation, or other circumstances beyond one's control. 272,343 These constraints inhibit dialogue about clinical problems clashing with professional obligations such as to reduce harm and avoid unnecessary suffering and to respect patient's dignity. As a consequence the perspective of the clinician is not heard in a way that allows to evaluate and address the situation causing the moral distress. ...
... The effect of moral distress on psychological and social functioning is moderate and short-term [28]. Epstein and Hamric [50] propose the concept of moral residue. This arises when individuals are repeatedly exposed to morally stressful situations. ...
... This process is called the crescendo effect. Consequently, a moral residual arises after accumulation, in which the individual and the social environment are affected in such a way that moral integrity is threatened [46,50]. ...
... Studies of MI mostly refer to MD as an institutional healthcare specific phenomenon caused by stressors related to values concerning the role of a healthcare professional [12,[15][16][17]29]. However MI is said to be the consequence of the violation of personal beliefs and expectations [36,50]. In the context of COVID-19, the border between these definitions seems to blur as decisions about protective equipment and vaccination may involve both personal values and expectations as well as professional expectations of HCWs to protect and ensure patient well-being. ...
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Ethical dilemmas for healthcare workers (HCWs) during pandemics highlight the centrality of moral stressors and moral distress (MD) as well as potentially morally injurious events (PMIEs) and moral injury (MI). These constructs offer a novel approach to understanding workplace stressors in healthcare settings, especially in the demanding times of COVID-19, but they so far lack clear identification of causes and consequences. A scoping review of moral stressors, moral distress, PMIEs, and MI of healthcare workers during COVID-19 was conducted using the databases Web of Science Core Collection and PsycINFO based on articles published up to October 2021. Studies were selected based on the following inclusion criteria: (1) the measurement of either moral stress, MD, PMIEs, or MI among HCWs; (2) original research using qualitative or quantitative methods; and (3) the availability of the peer-reviewed original article in English or German. The initial search revealed n = 149,394 studies from Web of Science and n = 34 studies from EBSCOhost. Nineteen studies were included in the review. Conditions representing moral stressors and PMIEs as well as MD and MI as their potential outcomes in healthcare contexts during COVID-19 are presented and discussed. Highlighting MD and MI in HCWs during COVID-19 brings attention to the need for conceptualizing the impact of moral stressors of any degree. Therefore, the development of a common, theoretically founded model of MD and MI is desirable.
... when factors prevent healthcare workers from providing proper care; Jameton, 1984Jameton, , 2017. While moral distress may be transient and resolves on its own, researchers have proposed that it may evolve into moral injury (Čartolovni et al., 2021;Epstein & Hamric, 2009;Williams et al., 2020) which is characterized by persistent psychological, existential and/or spiritual pain resulting from the values violation (Griffin et al., 2019;Litz et al., 2009). Moral injury is associated with mental health problems, including posttraumatic stress disorder (PTSD) and suicidal ideation (Bryan et al., 2013;Griffin et al., 2019;Litz et al., 2009). ...
... Third, results of this study also suggest that early intervention may be warranted for FHCWs who experience moral distress. It has been proposed that moral distress may be a precursor to moral injury for some individuals (Čartolovni et al., 2021;Epstein & Hamric, 2009;Williams et al., 2020) and one study of FHCWs during COVID-19 showed that over 3 months, moral distress did not resolve on its own (Hines et al., 2021). Studies suggest that among those with PTSD, moral injury can often be effectively treated with evidence-based PTSD treatment (e.g., Held et al., 2018). ...
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Introduction: Little is known about the relationship between moral distress and mental health problems. We examined moral distress in 2579 frontline healthcare workers (FHCWs) caring for coronavirus disease 2019 (COVID-19) patients during the height of the spring 2020 pandemic surge in New York City. The goals of the study were to identify common dimensions of COVID-19 moral distress; and to examine the relationship between moral distress, and positive screen for COVID-19-related posttraumatic stress disorder (PTSD) symptoms, burnout, and work and interpersonal functional difficulties. Method: Data were collected in spring 2020, through an anonymous survey delivered to a purposively-selected sample of 6026 FHCWs at Mount Sinai Hospital; 2579 endorsed treating COVID-19 patients and provided complete survey responses. Physicians, house staff, nurses, physician assistants, social workers, chaplains, and clinical dietitians comprised the sample. Results: The majority of the sample (52.7%-87.8%) endorsed moral distress. Factor analyses revealed three dimensions of COVID-19 moral distress: negative impact on family, fear of infecting others, and work-related concerns. All three factors were significantly associated with severity and positive screen for COVID-19-related PTSD symptoms, burnout, and work and interpersonal difficulties. Relative importance analyses revealed that concerns about work competencies and personal relationships were most strongly related to all outcomes. Conclusion: Moral distress is prevalent in FHCWs and includes family-, infection-, and work-related concerns. Prevention and treatment efforts to address moral distress during the acute phase of potentially morally injurious events may help mitigate risk for PTSD, burnout, and functional difficulties.
... As a result, the individual's "moral residue" is thought to increase. 6 As one's moral residue "crescendos" over time, the health care professional may even experience moral injury. Moral injury occurs when one's "deeply held moral beliefs" are threatened by one's actions or inactions. ...
... Previously identified risk factors for moral distress are numerous and include certain patient factors (such as providing care requested by a patient or surrogate that the clinician believes is futile), clinician factors (such as an inability to speak up), and institutional/unit factors (such as fear of litigation). 6 During the current pandemic, some of these risks for moral distress have become more prevalent, while new pandemic-specific risks have developed. Table 1 lists some causes of moral distress during the pandemic from the author's experience as a practicing palliative care clinician and ethics consultant. ...
Article
Palliative care practitioners have encountered morally distressing situations during the COVID-19 pandemic, and have supported their colleagues experiencing moral distress. Familiarity with the concept of moral distress and with COVID-specific causes of moral distress may help palliative care practitioners recognize moral distress in themselves and in their colleagues. This essay provides a brief review of the concept of moral distress, a list of potential COVID-19 specific causes of moral distress, and a list of organizational, team, and individual interventions to promote resilience.
... 8 Internal factors such as lack of knowledge, moral and personal failure, 9 lack of self-confidence, inability to cope with perceived pain and suffering, and conflict with religious or spiritual beliefs. [9][10][11][12] Factors related to clinical conditions, including conditions that harm the patient, such as aggressive and useless treatments, inadequate care, unnecessary laboratory tests, inadequate pain management, complete lack of treatment, and deception and compulsive consent of the patient for treatment. 11 Finally, the most common external factors include shortage of manpower, poor teamwork, poor communication, 8 inconsistent treatment programs, and conflict between physicians and nurses about treatment methods 13 (Table 1). ...
... Several studies have shown that there is a direct relationship between work experience and the level of MD in nurses. 1,12,16 But in other studies, there was no relationship between MD and work experience. [17][18][19][20] Also, the results of a study showed that the prevalence of MD among older nurses with more work experience in the current job position is higher than nurses with less work experience. ...
Article
Background Moral distress is a complex and challenging issue in the nursing profession that can negatively affect the nurses’ job satisfaction and retention and the quality of patient care. This study focused on describing the resources and constraints, consequences, and interventions of moral distress in nurses. Methods In a literature review, an extensive electronic search was conducted in databases including PubMed, ISI, Scopus as well as Google Scholar search engine using the keywords including “moral distress” and “nurses” to identify resources, constraints, consequences, and interventions about moral distress in nurses, from the earliest records up to 26 December 2020. The required data were extracted from 61 relevant studies by two independent reviewers. Results Resources and constraints in the occurrence of moral distress among nurses can be divided into three general categories including internal factors, clinical factors, and external factors. The consequences of moral distress on nurses and the medical system reduced moral sensitivity, development of psychological and physical health problems, and the intention to leave the profession. The potential effective interventions were the implementation of integrated communication programs, strengthening physician–nurse collaboration, nursing involvement in clinical decision-making and end-of-life issues, social support, using a resiliency bundle, interdisciplinary discussion, and promoting nurses’ ethical and communication skills. Conclusion There are a wide range of resources and constraints impacting moral distress in nurses that could lead to negative consequences. Further studies are necessary to identify, evaluate, and implement a range of potential effective interventions for the management of moral distress in nurses.
... g., patient-centred care conflicts, participating in non-beneficial treatments), 2) the intensive care unit (ICU) and work staff (e.g., ethical conflicts with colleagues, lack of shared decision-making, team discordance) and 3) the healthcare system itself (e.g., poor communication, institutional policies) (Hamric and Epstein, 2017). When a health professional is repeatedly unable over time to perform actions they consider ethically correct, a "moral residue" is created (Webster and Bayliss, 2000;Epstein and Hamric, 2009) and the negative feelings remain after the situation has passed, leading to a "crescendo" effect, with increasingly intense responses to new experiences (Epstein and Hamric, 2009). ...
... g., patient-centred care conflicts, participating in non-beneficial treatments), 2) the intensive care unit (ICU) and work staff (e.g., ethical conflicts with colleagues, lack of shared decision-making, team discordance) and 3) the healthcare system itself (e.g., poor communication, institutional policies) (Hamric and Epstein, 2017). When a health professional is repeatedly unable over time to perform actions they consider ethically correct, a "moral residue" is created (Webster and Bayliss, 2000;Epstein and Hamric, 2009) and the negative feelings remain after the situation has passed, leading to a "crescendo" effect, with increasingly intense responses to new experiences (Epstein and Hamric, 2009). ...
Background From the beginning, the COVID-19 pandemic increased ICU workloads and created exceptionally difficult ethical dilemmas. ICU staff around the world have been subject to high levels of moral stress, potentially leading to mental health problems. There is only limited evidence on moral distress levels and coping styles among Spanish ICU staff, and how they influenced health professionals’ mental health during the pandemic. Objectives To assess moral distress, related mental health problems (anxiety and depression), and coping styles among ICU staff during the first wave of the COVID-19 pandemic in Spain. Design: Cross-sectional. Settings and participants: The study setting consisted of ICUs and areas converted into ICUs in public and private hospitals. A total of 434 permanent and temporary ICU staff (reassigned due to the pandemic from other departments to ICUs) answered an online questionnaire between March and June 2020. Methods Sociodemographic and job variables, moral distress, anxiety, depression, and coping mechanisms were anonymously evaluated through a self-reported questionnaire. Descriptive and correlation analyses were conducted, and multivariate linear regression models were developed to explore the predictive ability of moral distress and coping on anxiety and depression. Results Moral distress during the pandemic is determined by situations related to the patient and family, the ICU unit, and resource management of the organisations themselves. ICU staff already reached moderate levels of moral distress, anxiety, and depression during the first wave of the pandemic. Temporary ICU staff (redeployed from other units) obtained higher scores in these variables (p = 0.04, p = 0.038, and p = 0.009, respectively) than permanent ICU staff, as well as in greater intention to leave their current position (p = 0.03). This intention was also stronger in health staff working in areas converted into ICUs (45.2%) than in normal ICUs (40.2%) (p = 0.02). Moral distress, coupled with primarily avoidance-oriented coping styles, explains 37% (AdR²) of the variance in anxiety and 38% (AdR²) of the variance in depression. Conclusions Our study reveals that the emotional well-being of ICU staff was already at risk during the first wave of the pandemic. The moral distress they experienced was related to anxiety and depression issues, as well as the desire to leave the profession, and should be addressed, not only in permanent ICU staff, but also in temporary ICU staff, redeployed to these units as reinforcement workers.
... In this new definition, he emphasized the psychoemotional responses of not acting in a morally appropriate way. Reactive distress is also referred to as "moral residue" and was later recognized as a concept that is different from, yet related to, moral distress [21,29]. In addition to moral residue, other constructs, such as emotional distress, moral uncertainty and moral dilemmas, can all be associated with and partially overlap with moral distress. ...
... If nursing staff members cannot or choose not to discuss or act upon the problem causing moral distress, it can contribute to issues with quality of care and patient satisfaction [34]. This may be in line with what Jameton describes as moral residue, which is both a contributor to and a consequence of moral distress (see Fig. 1) [21,28,29]. The residual effect may also create consequences for the system, such as issues of nurse retention and staff shortages [34]. ...
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Background Dementia is a public health priority worldwide due to its rapidly increasing prevalence and poses challenges with regard to providing proper care, including end-of-life care. This study is part of a research project about nursing staff members’ experiences with providing palliative care for people with severe dementia in long-term care facilities. In an earlier study, we found that structural barriers that complicated the provision of palliative care led to moral distress among nursing staff. In this study, we performed a secondary analysis of the same data set to gain a deeper understanding of nursing staff members experiences of moral distress while providing palliative care for residents with severe dementia in long-term care facilities. Methods A qualitative, descriptive design was used. Data were collected during in-depth interviews with 20 nursing staff members from four Norwegian long-term care facilities. Content previously identified as moral distress was reanalysed by thematic text analysis, as described by Braun and Clarke, to gain a deeper understanding of the phenomenon. Results The nursing staff members’ experiences of moral distress were generally of two types: those in which nursing staff members felt pressured to provide futile end-of-life treatment and those in which they felt that they had been prevented from providing necessary care and treatment. Conclusion The findings indicate that nursing staff members’ experiences of moral distress were related to institutional constraints such as time limitations and challenging prioritizations, but they were more often related to value conflicts. Nursing staff members experienced moral distress when they felt obligated to provide care and treatment to residents with severe dementia that conflicted with their own values and knowledge about good palliative care. Both education interventions focused on improving nursing staff members’ skills regarding communication, ethical judgement and coping strategies; in addition, supportive and responsive leadership may have significant value with regard to reducing moral distress. Our findings indicate a need for further research on interventions that can support nursing staff members dealing with ethical conflicts in providing palliative care to residents with dementia.
... Deciding in moral situations is stressful, and stress itself alters moral judgment (Singer et al., 2017;Starcke et al., 2012;Youssef et al., 2012;Zhang et al., 2018). Stress and concerns related to the ethical aspects of practice and professional duties among healthcare and medical workers are defined as moral distress (Epstein and Hamric, 2009;Varcoe et al., 2012). Moral distress is caused by a discrepancy between moral values and one's actions that occurred due to conditional constraints (Epstein & Hamric, 2009). ...
... Stress and concerns related to the ethical aspects of practice and professional duties among healthcare and medical workers are defined as moral distress (Epstein and Hamric, 2009;Varcoe et al., 2012). Moral distress is caused by a discrepancy between moral values and one's actions that occurred due to conditional constraints (Epstein & Hamric, 2009). COVID-19 challenges have led clinicians to experience moral distress to a great degree, mainly due to important practice changes during this period (Cacchione, 2020;Dunham et al., 2020;Kok et al., 2020). ...
Article
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With the coronavirus disease 2019 (COVID-19) outbreak, healthcare and medical professions face challenging situations. The high number of COVID-19 infected patients, scarce resources, and being vulnerable to the infection are among the reasons that may influence clinicians’ moral decision-making. Furthermore, healthcare workers may be carriers of coronavirus, resulting in their social interactions to involve moral decision-making. This study aimed to investigate the effect of working in the frontline on psychological and cognitive factors and how these factors influence moral decision-making in clinicians during the pandemic. Further, we evaluated the impact of these factors on compliance with social distancing. Clinicians who worked in hospitals allocated to coronavirus disease patients participated in our study. We designed an online survey containing eight dilemmas to test moral decision-making in clinicians. Information on clinicians’ behavior and psychological state during the COVID-19 pandemic including the degree of respect to social distancing, sources of stress, and dead cases of COVID-19 they confronted with were collected. First, the relation between these measures and moral decision-making was assessed. Next, we used multiple regression analysis to evaluate the degree to which these factors can predict variances in morality. Based on our results, clinicians’ most important source of stress was the infection of their families. Stress, estimated chance of self-infection, job satisfaction, and age predicted utilitarian behavior among them. Moreover, age, number of death cases of COVID-19 they confronted, perceived risk of infection, and stress were positively correlated to compliance with social distancing. Our results have critical implications in implementing policies for healthcare principals.
... Moral distress was initially defined Open Access *Correspondence: daddiss@taskforce.org 4 Focus Area for Compassion and Ethics, The Task Force for Global Health, 330 W. Ponce de Leon Ave, Decatur, GA 30030, USA Full list of author information is available at the end of the article by Jameton as "the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right" [3]. Moral distress has been characterized primarily in nurses and other healthcare workers, as well as in first responders and humanitarian settings [4][5][6][7][8]. ...
... Moral distress was initially defined Open Access *Correspondence: daddiss@taskforce.org 4 Focus Area for Compassion and Ethics, The Task Force for Global Health, 330 W. Ponce de Leon Ave, Decatur, GA 30030, USA Full list of author information is available at the end of the article by Jameton as "the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right" [3]. Moral distress has been characterized primarily in nurses and other healthcare workers, as well as in first responders and humanitarian settings [4][5][6][7][8]. Moral distress is associated with all three dimensions of burnout (emotional exhaustion, depersonalization, and decreased personal accomplishment) [5], and has been linked to poor work performance and staff turnover [6]. ...
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Background As ‘disease detectives’ and directors of public health programs, field epidemiologists play essential roles in protecting public health. Although ethical issues receive considerable attention in medical and research settings, less is known about ethical challenges faced by field epidemiologists in public health programs. Similarly, little is known about moral distress among field epidemiologists, i.e., situations in which they are constrained from acting on what they know to be morally right. Moral distress is strongly associated with empathy fatigue, burnout, reduced job retention, and disengagement. To better understand ethics training needs for field epidemiologists, in February 2019, members of TEPHIConnect, an online and mobile networking platform for Field Epidemiology Training Program (FETP) alumni, were invited to participate in an anonymous survey about ethical challenges and moral distress. Results Among 126 respondents from 54 countries, leading causes of ethical dilemmas included inadequate informed consent (61%), inequitable allocation of resources (49%), and conflicts of interest (43%). These occur primarily in settings of disease outbreaks (60%); research (55%); and public health programs at the state, province, or national level (45%) or community level (43%). Work-related moral distress was reported by 91% of respondents, including 26% who experience it “frequently” or “almost always.” Field epidemiologists working in low- and low-middle income countries were more likely to report moral distress “frequently” or “almost always” than those in higher-income countries (33.0% vs 9.1%, P = 0.006). The most common perceived contributors to moral distress included excessive stress and work demands (30%) and inadequate support from leaders (25%). Conclusions Field epidemiologists face significant work-related ethical challenges, which are endemic to public health and political systems. A substantial proportion of field epidemiologists also experience some degree of moral distress, often in association with these challenges. These findings indicate an unmet need among field epidemiologists for support in navigating ethical challenges, as well as for resources to address the human and professional consequences of moral distress.
... Moral residue, which has been described by Webster and Baylis as "that which each of us carrie[s] with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised," is thought to be a byproduct of experiencing a moral dilemma or repeated instances of moral distress. [35][36][37] Even without a sense of having seriously compromised oneself, clinicians can experience moral residue as "lingering feelings after a morally problematic situation has passed." 37 Our moral residue can influence how we make decisions, risking reactionary rather than deliberative responses. ...
... [35][36][37] Even without a sense of having seriously compromised oneself, clinicians can experience moral residue as "lingering feelings after a morally problematic situation has passed." 37 Our moral residue can influence how we make decisions, risking reactionary rather than deliberative responses. To overcome this phenomenon and as part of the process of providing optimal pediatric gender care, it is important to examine one's moral residue and identify ways to mitigate the different types of moral distress. ...
Article
Using case examples and other common scenarios, the authors outline several types of moral distress that clinicians may experience when providing pediatric gender-affirming care. The authors also offer strategies for managing moral distress and issue a call to action for professional organizations to enhance support for gender-affirming clinicians.
... For example, most interviewers felt that they should issue culturally appropriate tokens to bereaved families and refer respondents for professional health and social care but could not because of restrictive institutional policies. Constraints to actions can also be internal or personal [67]. Verbal autopsy interviewers described a perceived lack of skills in bereavement counselling and lack of adequate personal resources to comfort or alleviate the suffering of respondents and bereaved families. ...
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Background Verbal autopsy is a pragmatic approach for generating cause-of-death data in contexts without well-functioning civil registration and vital statistics systems. It has primarily been conducted in health and demographic surveillance systems (HDSS) in Africa and Asia. Although significant resources have been invested to develop the technical aspects of verbal autopsy, ethical issues have received little attention. We explored the benefits and burdens of verbal autopsy in HDSS settings and identified potential strategies to respond to the ethical issues identified. Methods This research was based on a case study approach centred on two contrasting HDSS in Kenya and followed the Mapping-Framing-Shaping Framework for empirical bioethics research. Data were collected through individual interviews, focus group discussions, document reviews and non-participant observations. 115 participants were involved, including 86 community members (HDSS residents and community representatives), and 29 research staff (HDSS managers, researchers, census field workers and verbal autopsy interviewers). Results The use of verbal autopsy data for research and public health was described as the most common potential benefit of verbal autopsy in HDSS. Community members mentioned the potential uses of verbal autopsy data in addressing immediate public health problems for the local population while research staff emphasized the benefits of verbal autopsy to research and the wider public. The most prominent burden associated with the verbal autopsy was emotional distress for verbal autopsy interviewers and respondents. Moral events linked to the interview, such as being unsure of the right thing to do (moral uncertainty) or knowing the right thing to do and being constrained from acting (moral constraint), emerged as key causes of emotional distress for verbal autopsy interviewers. Conclusions The collection of cause-of-death data through verbal autopsy in HDSS settings presents important ethical and emotional challenges for verbal autopsy interviewers and respondents. These challenges include emotional distress for respondents and moral distress for interviewers. This empirical ethics study provides detailed accounts of the distress caused by verbal autopsy and highlights ethical tensions between potential population benefits and risks to individuals. It includes recommendations for policy and practice to address emotional and moral distress in verbal autopsy.
... Crescendo Effect 1. Epstein and Hamric (2009) suggest that moral distress leaves a 'moral residue' such that after repeated experiences of moral distress, one's feelings of distress, rather than return to baseline, accumulate-creating a crescendo effect over time. 2. We conceptualise of moral residue as originally suggested by Bernard Williams (1965) and Ruth Marcus (1980) as signalling the presence or experience of a true moral dilemma. ...
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Aims and objectives: To explore moral distress empirically and conceptually, to understand the factors that mitigate and exacerbate moral distress and construct a model that represents how moral distress relates to its constituent parts and related concepts. Background: There is ongoing debate about how to understand and respond to moral distress in nursing practice. Design: The overarching design was feminist empirical bioethics in which feminist interpretive phenomenology provided the tools for data collection and analysis, reported following the COREQ guidelines. Using reflexive balancing, the empirical data were combined with feminist theory to produce normative recommendations about how to respond to moral distress. The Moral Distress Model presented in this paper is a culmination of the empirical data and theory. Methods: Using feminist interpretive phenomenology, critical care nurses in the United Kingdom (n = 21) were interviewed and data analysed. Reflexive Balancing was used to integrate the data with feminist theory to provide normative recommendations about how to understand moral distress. Results: There are five compounding factors that exacerbate/ mitigate nurses' experiences of moral distress: epistemic injustice; the roster lottery; conflict between one's professional and personal responsibilities; ability to advocate and team dynamics. In addition to the causal connection and responses to moral distress, these factors make up the moral distress model which can guide approaches to mitigate moral distress. Conclusions: The Moral Distress Model is the culmination of these data and theorising formulated into a construct to explain how each element interacts. We propose that this model can be used to inform the design of interventions to address moral distress.
... [1][2][3][4]11 Moral distress was also higher for clinicians who had been practicing more than 10 years, which may be due to a "crescendo effect" whereby repeated instances of unaddressed moral distress result in a greater level of moral distress over time. 11,19 Not surprisingly, we also found that moral distress was signifi cantly higher among clinicians who reported burnout and considered leaving their position. 3,14 Intriguingly, despite the overall high levels of moral distress, clinicians were less likely to report experiencing frequent moral distress when taking care of patients receiving MCS than when caring for patients with a chronic critical illness or sustained multisystem organ failure. ...
Article
Background Although use of mechanical circulatory support is increasing, it is unclear how providing such care affects clinicians’ moral distress. Objective To measure moral distress among intensive care unit clinicians who commonly care for patients receiving mechanical circulatory support. Methods In this prospective study, the Moral Distress Scale-Revised was administered to physicians, nurses, and advanced practice providers from 2 intensive care units in an academic medical center. Linear regression was used to assess whether moral distress was associated with clinician type, burnout, or desire to leave one’s job. Clinicians’ likelihood of reporting frequent moral distress when caring for patients receiving mechanical circulatory support vs other critically ill patients also was assessed. Results The sample comprised 102 clinicians who had a mean (SD) score of 100.5 (51.6) on the Moral Distress Scale- Revised. After adjustment for clinician characteristics, moral distress was significantly higher in registered nurses than physicians/advanced practice providers (115.9 vs 71.0, P < .001), clinicians reporting burnout vs those who did not (114.7 vs 83.1, P = .003), and those considering leaving vs those who were not (121.1 vs 89.2, P = .001). Clinicians were more likely to report experiencing frequent moral distress when caring for patients receiving mechanical circulatory support (26.5%) than when caring for patients needing routine care (10.8%; P = .004), but less likely than when caring for patients with either chronic critical illness (57.8%) or multisystem organ failure (56.9%; both P < .001). Conclusion Moral distress was high among clinicians who commonly care for patients receiving mechanical circulatory support, suggesting that use of this therapy may affect well-being among intensive care unit clinicians.
... Even if the level is low, moral distress may accumulate over time and may give rise to moral distress residue crescendo. This concept was first studied by Epstein & Hamric [35] who explored the effect of moral distress over time and its consequences on healthcare professionals and patients: even if the event that caused moral distress among a certain healthcare professional is solved, a moral residue can remain, raising up the exposition level baseline. Given that, our findings suggest that interventions are needed to help prevent crescendo effects in healthcare professionals working in community and hospital settings. ...
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Moral distress is a concern for all healthcare professionals working in all care settings. Based on our knowledge, no studies explore the differences in levels of moral distress in hospital and community settings. This study aims to examine the level of moral distress among healthcare professional working in community or hospital settings and compare it by demographic and workplace characteristics. This is a cross-sectional study. All the professionals working in the hospitals or community settings involved received personal e-mail invitations to participate in the study. The Moral Distress Thermometer was used to measure moral distress among healthcare professionals. Before data collection, ethical approval was obtained from each setting where the participants were enrolled. The sample of this study is made up of 397 healthcare professionals: 53.65% of the sample works in hospital setting while 46.35% of the sample works in community setting. Moral distress was present in all professional groups. Findings have shown that nurses experienced level of moral distress higher than other healthcare professionals (mean: 4.91). There was a significant differences between moral distress among different professional categories (H(6) = 14.407; p < 0.05). The ETA Coefficient test showed significant variation between healthcare professionals working in community and in hospital settings. Specifically, healthcare professionals who work in hospital experienced a higher level of moral distress than those who work in community settings (means 4.92 vs. means 3.80). The results of this study confirm that it is imperative to develop educational programs to reduce moral distress even in those settings where the level perceived is low, in order to mitigate the moral residue and the crescendo effect.
... 9,10,15,16 Frequently experienced morally stressful situations may cause moral residue, 'that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised', 17 resulting in increased levels of moral distress, the so-called crescendo effect. 18 Rushton et al. 19 claim that 'few solutions have been proposed for alleviating a problem that is only expected to escalate as healthcare becomes more complex' (p. 82). ...
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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.
... Recently, Batho, and Pitton [12] argued that the main characteristic of moral distress is the perception of being morally compromised for not being able to be oneself in a situation in which you feel that you should (but were not) able to do the right thing. Epstein and Hamric proposed a crescendo effect model of moral distress [13] by focusing on the difference between the initial moral distress that is experienced during a situation, and the moral residue that represents the lingering angst that continues after the event. Webster and Bayliss defined moral residue as "that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised" [14] (p. ...
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The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians’ experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020–February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment.
... This type of moral distress is believed to arise from the cumulative effect of working in environments of low ethical climate. 12 In many health professions including nursing, medicine, physiotherapy and midwifery, moral distress has been identified as a concerning feature of clinical practice. 8,[13][14][15][16] Withdrawal from client care, 17,18 workforce attrition 18,19 and psychological harm 18 have been linked to moral distress. ...
Article
Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers’ evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as ‘a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments’. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress.
... Here, acute moral distress can decrease when an issue is resolved only to increase again when faced with a similar situation and the clinician still harbors painful feeling. 67 We do not know if caring for those with serious, life-limiting illness creates this crescendo effect. However, death of a patient has been shown to provoke emotional reactions in clinicians. ...
Article
Background Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention. Research purpose The purpose of this article was to investigate the nature of clinician distress. Research design Qualitative inductive dimensional analysis. Participants and research context After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis. Ethical considerations This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis. Findings A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians’ perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one’s values due to a precipitating event. Discussion This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician’s own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed. Conclusion For clinicians, learning to recognize one’s perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.
... An ethical dilemma arises when we are confronted with a situation with two morally justifiable solutions, none of which is entirely satisfactory (1). In the course of their daily work, health care professionals (HCPs) encounter a broad range of ethical dilemmas (2)(3)(4), which often result in a moral distress for HCPs (5,6). A critical requirement for a successful response to an ethical dilemma is a strong foundation in medical professionalism cultivated during medical training and consolidated during professional work experience and career development (7)(8)(9). ...
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Aim: To assess the differences in the way how Slovenian and Croatian health care professionals (HCPs) confront ethical dilemmas and perceive the role of hospital ethics committees (HECs). Methods: This cross-sectional, survey-based study involved HCPs from three Slovenian and five Croatian university medical centers (UMC). The final sample sizes were 308 (244 or 79.2% women) for Slovenia and 485 (398 or 82.1% women) for Croatia. Results: Compared with Croatian physicians, Slovenian physicians reported a higher share of ethical dilemmas regarding waiting periods for diagnostics or treatment, suboptimal working conditions due to interpersonal relationships in the ward, and end-of-life treatment withdrawal, and a lower share regarding access to palliative care and patient information protection. Compared with Croatian nurses, Slovenian nurses reported a lower share of ethical dilemmas regarding the distribution of limited resources, recognizing the patient's best interests, and access to palliative care. Compared with Croatian other HCPs, Slovenian other HCPs reported a lower burden of ethical dilemmas regarding waiting periods for diagnostics or treatment, distribution of limited resources, and access to palliative care. When encountering an ethical dilemma, all HCPs in both countries would first consult their colleagues. Slovenian and Croatian HCPs recognized the importance of the HECs to a similar extent, but viewed their role differently. Conclusion: Croatian and Slovenian HCPs are confronted with different ethical dilemmas and perceive the role of HECs differently.
... Moral distress occurs when one knows the ethically correct action to take, but feels powerless to take that action. 21 Participation in EOHD has been found to be a source of moral distress and professional burnout for involved clinicians 22 . Emergency physicians may be particularly vulnerable to this source of moral distress and its manifestation as burnout because of their role as gatekeepers to EMTALA services such as EOHD. ...
Article
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Undocumented immigrants with end-stage renal disease in the United States are uniquely disadvantaged in their ability to access dialysis. This article examines the unique circumstances of the medical condition and healthcare system, including the relevant legal and regulatory influences that largely relegate undocumented immigrants to relying on emergency-only dialysis through a hospital's Emergency Medical Treatment and Labor Act obligations. We explore the ethical implications of this current state, emphasizing the adverse effects on patients and staff alike. We also review necessary actions that range from the actions an individual emergency physician to changes needed in federal policy.
... Overall, ECNQ-CCV describes four variables concerning the ethical conflict: frequency, intensity, exposure to the conflict (which is the product of the former two variables) and the types of ethical conflict [12]. Since the moral residue based on the crescendo effect is a common feeling lingering after repeated ethically problematic situations, it is significantly essential to measure the exposure to ethical conflict in ICU setting by the score of frequency multiplied by intensity [20,21]. Therefore, the ECNQ-CCV is a sensitive tool to detect the exposure to ethical conflict and discriminate different types of conflicts. ...
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Background Ethical conflicts are common in the critical care setting, and have compromised job satisfaction and nursing care quality. Using reliable and valid instruments to measure the ethical conflict is essential. This study aimed to translate the Ethical Conflict in Nursing Questionnaire — Critical Care Version into Chinese and determine the reliability and validity in the population of Chinese nurses. Methods Researchers obtained permission and followed the translation-backward method to develop the Chinese version of the Ethical Conflict in Nursing Questionnaire — Critical Care Version (ECNQ-CCV-C). Relevant psychometric properties were selected according to the Consensus-based standards for the selection of health status measurement instruments checklist. Critical care nurses were recruited from two tertiary public hospitals in Hangzhou, Zhejiang Province, and Kunming, Yunnan Province. Of the 264 nurses we approached, 248 gave their consent and completed the study. Results The ECNQ-CCV-C achieved Cronbach’s alphas 0.902 and McDonald’s omega coefficient 0.903. The test-retest reliability was satisfactory within a 2-week interval (intraclass correlation coefficient = 0.757). A unidimensional structure of the ECNQ-CCV-C was determined. Confirmatory factor analysis supported acceptable structure validity. Concurrent validity was confirmed by a moderate relation with a measure for hospital ethical climate ( r = − 0.33, p < 0.01). The model structure was invariant across different gender groups, with no floor/ceiling effect. Conclusions The ECNQ-CCV-C demonstrated acceptable reliability and validity among Chinese nurses and had great clinical utility in critical care nursing.
... In our findings, it is noteworthy that moral distress resulted from institutional and contextual factors, which can predict decreased job satisfaction among nurses acting as PAs, which is consistent with other studies regardless of nurses' care settings or cultural backgrounds [45,46]. The consistency can be explained by 'the crescendo effect model' in Epstein and Hamric's terms [47], which they explained on the premise of Webster and Baylis's concept of moral residue [48]. They described 'moral residue' as what one continues to feel after the morally problematic situation has passed. ...
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Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this study was to verify the impact of nurse–physician collaboration, moral distress, and professional autonomy on job satisfaction among nurses acting as physician assistants. Descriptive and correlational research was conducted on a convenience sample of 130 nurses from five general hospitals in South Korea. In the final regression model, the adjusted R square was significant, explaining 38.2% of the variance of job satisfaction (F = 8.303, p < 0.001), where ‘cooperativeness’ (β = 0.469, p = 0.001) from nurse–physician collaboration, ‘institutional and contextual factor’ from moral distress (β = −0.292, p = 0.014), and professional autonomy (β = 0.247, p = 0.015) were included. In hospital environments, a more cooperative inter-professional relationship between nurses and physicians led to less moral distress caused by organisational constraints. A higher level of professional autonomy among nurses acting as physician assistants is required to increase their job satisfaction.
... These concepts are themselves defined in quite varied ways (see, for example, definitions of 'moral distress' in a systematic review by Morley et al. [110]), potentially leading to additional conceptual confusion. Identifying triggers for moral distress is important, as high levels of moral distress are known to have negative impacts on work environments and lead to increased levels of compassion fatigue, increased staff turnover rates and poorer patient outcomes [110][111][112]. However, it is also possible that the requirement that, to be identified as an ethical challenge, the situation must invoke stress or distress might result in the under-identification of ethical challenges. ...
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Background Despite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature. Methods Rapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021. Results 393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study. Conclusions Only 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.
... [20][21][22] Moral distress can also lead to longer term feelings that have been labeled ''moral residue,'' which lingers long after a morally problematic situation has passed, resulting in a lasting and profound loss of moral identity. 23 Third, in this survey, 73% of the respondents felt that a major contributor to their moral distress with regard to providing emergent dialysis to undocumented immigrants was the suffering of patients due to inadequate routine three times per week dialysis treatments. Studies have explored the illness experience of undocumented immigrants on emergent dialysis and found themes of profound symptom burden, near death experiences, and family and social consequences of accommodating emergent dialysis experienced by patients undergoing emergent hemodialysis, supporting the sentiments shared by the participants in our study. ...
Article
Purpose: To understand clinicians' perspectives on dialysis care of undocumented immigrants. Methods: A 21-item Internet-based survey using Survey Monkey? was sent to 765 physicians and nurses at a safety-net hospital located in Indianapolis, IN. Moral distress thermometer score was used to assess moral distress (MD). Participants were asked to rate their MD regarding five ethically challenging clinical situations: (1) frail patients with multiple comorbidities and poor quality of life, (2) patients with dementia, (3) a noncompliant patient with frequent emergency room (ER) visits, (4) violent patients with potential harm to others, and (5) undocumented immigrants receiving emergent dialysis only. Key Results: There were 299 of 775 participants (38.5% response rate) who completed the survey; 49.5% were physicians. Nearly half (48%) reported severe MD and 33% reported none to mild. In adjusted ordered logistic regression, females had significantly higher odds of MD (odds ratio [OR]=2.12, CI 1.03?4.33), and nurses had lower MD than fellows/residents (OR=0.14, CI 0.03?0.63). Over 70% of respondents attributed their distress to suffering of patients due to inadequate dialysis and tension between what is considered ethical and the law allows or forbids; 78% believed the patients' quality of life to be worse than those who receive routine hemodialysis. Among nephrologists, caring for these patients led to MD levels like that of dealing with a violent dialysis patient. Conclusions: Emergent-only dialysis causes significant MD in clinicians. Legal and fiscal policies need to be balanced with the ethical and moral commitments of providers for ensuring standard of care to all.
... 5 With moral distress, nurses and other health care professionals working in an environment where their core values feel violated can face frustration, anger, guilt, anxiety, withdrawal, and self-blame. 6 This in turn can result in increased burnout, turnover, negative perceptions about their institutions, withdrawal from patients affecting quality of care, and leaving their profession altogether. 7 A major source of moral distress for nurses has been the often ambivalent and sometimes hostile public attitudes toward vaccines, masks, and COVID-19 safety, including among patients in hospitals. ...
Article
Nurses face unprecedented harms from the COVID-19 pandemic. A survey by AMN Healthcare found that registered nurses experienced significantly elevated levels of stress, burnout, and other challenges that led nearly 1 million to consider leaving nursing altogether. Despite the challenges, a confluence of positive factors present great confidence that the nursing profession can bounce back and become much stronger due to lessons learned and hardships overcome during the pandemic. There is near-universal awareness that solving the significant challenges to nursing is vitally important, because the health of the American people depends on the health of the nation’s nurses.
... For example, nurses and clinicians knowing the ethically appropriate action to take, but not being able to pursue due to clinical situations and institutional obstacles has been reported as morally injured (Giwa et al., 2021). Repeated exposure to such situations may not only lead to MI, but also contribute to increased rates of emotional outbursts, post-traumatic stress disorder (PTSD), burnout, job dissatisfaction, and intention to leave the clinical position (Aultman and Wurzel, 2014;Epstein and Hamric, 2009;Kingston, 2020;Kopala and Burkhart, 2005;Rushton et al., 2015;Scotland-Coogan and Davis, 2016). ...
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Moral injuries can occur when perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. The COVID-19 crisis highlighted the fact that psychosocial stressors at work, such as high emotional demands, are placing Canadian healthcare workers at risk of moral injuries. Evidence linking psychosocial stressors at work to moral injuries are needed to better predict, prevent and manage moral injuries, as these stressors are frequent and modifiable occupational risk factors. This protocol presents a study aiming to: 1) understand workplace events having the potential to either cause or reduce moral injuries, 2) predict the risk and severity of moral injuries using a disease prevention model, 3) identify biological signatures (biomarkers) associated with psychosocial stressors at work and moral injuries and 4) elaborate preliminary guidelines of organizational practices for frontline healthcare workers to reduce and manage moral injuries. This study is a mixed methods research with three components: qualitative, quantitative and biological. The data collection has been completed and because of the COVID-19 pandemic, it was adjusted to allow for gathering qualitative and quantitative data remotely. Frontline healthcare workers and leaders were included. Through focus groups and individual interviews, and an online questionnaire, events and psychosocial working conditions that may increase the risk of moral injuries will be documented. In addition, blood samples which were collected from a sub-sample of volunteer participants will measure an innovative set of biomarkers associated with vulnerability to stress and mental health. Data analyses are ongoing. We anticipate to identify workplace events that may trigger moral injuries. We expect that potential predictors of moral injury risk occurrence and severity will be identified from psychosocial stressors at work that can be improved by implementing organizational practices. We also expect to observe a different mental health state and biological inflammation signature across workers exposed compared to workers not exposed to psychosocial stressors at work. Based on these future findings, we intend to develop preliminary recommendations of organizational practices for managers. This research will contribute to expand our knowledge of the events in the workplace likely to generate or lessen the impact moral injuries, to build a model for predicting the risk of moral injuries at work, all in the specific context of the COVID-19 health crisis among healthcare workers.
... The findings remained significant even after controlling for the previous week's outcomes. The results support previous theory that moral distress can have cumulative effects (Epstein & Hamric 2009), such that even after controlling for the prior week's outcomes, endorsement of moral distress predicted increased mental health strain and burnout each week. These findings extend the work of previous researchers who have found that moral distress was a significant predictor of burnout, depression, anxiety, and PTSD (Kok et al. 2021;Plouffe et al. 2021). ...
Article
The COVID-19 pandemic has presented many novel situations that have amplified the presence of moral distress in healthcare. With limited resources to protect themselves against the virus and strict safety regulations that alter the way they work, healthcare providers have felt forced to engage in work behaviours that conflicted with their professional and personal sense of right and wrong. Although many providers have experienced moral distress while being physically in the workplace, others suffered while at home. Some healthcare providers worked in facilities that were unable to open during the pandemic due to restrictions, which could contribute to a sense of powerlessness and guilt. The current study assessed whether the ability to see patients each week impacted the relationship between an employee's moral distress and their mental health strain, burnout, and maladaptive coping. A total of 378 healthcare providers responded to weekly surveys over the course of 7 months (April 2020-December 2020). Hierarchical linear modeling techniques were used to examine the study variables over time. Results showed that moral distress predicted an individual's mental health strain and burnout, even after controlling for the prior week. However, moral distress was not a significant predictor of maladaptive coping. Interestingly, there was not a significant difference between the average ratings of moral distress between those who were able, and those who were not able to see patients, meaning that both groups experienced symptoms of moral distress. However, cross-level moderation results indicated that the ability to see patients magnified the relationships between moral distress and mental health strain and burnout over time. Implications of the results and recommendations for how moral distress should be addressed among healthcare providers are discussed.
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Zusammenfassung Ethik-Komitees gehören zum festen Bestandteil des Ethikmanagements und der Organisationsethik in klinischen Einrichtungen des Gesundheitswesens. Entsprechende Ethikstrukturen und die damit verbundenen Angebote stoßen hinsichtlich ihrer Wirksamkeit allerdings an ihre Grenzen. Ihre Arbeitsweisen sind häufig reaktiv und eine Verankerung in den entsprechenden Organisationsebenen fehlt. Ausgehend von diesen Limitationen der klinischen Ethikberatung hat sich die multiprofessionelle „Arbeitsgruppe Ethik“ am Universitätsklinikum Tübingen (UKT) um die Konzeption und Implementierung eines neuen Ansatzes zur nachhaltigen Integration von ethischen Reflexions- und Entscheidungsprozessen auf den Stationen des UKT bemüht. Mit dem Tübinger Modell der Ethikbeauftragten der Station verfolgt sie ein Pilotprojekt, das speziell geschulte Pflegekräfte aus allen Stationen des UKT als AnsprechpartnerInnen für ethische Fragen einsetzt. Damit stellen die Ethikbeauftragten eine Erweiterung zu etablierten Strukturen der Ethikberatung dar und ergänzen vorhandene Top-Down-Strategien. Der vorliegende Beitrag stellt die Zielsetzungen des Tübinger Modells dar und schildert erste Erfahrungen in der Umsetzung. Neben der Einbettung in organisationale Strukturen der Ethikberatung werden die stationsinternen und stationsübergreifenden Aufgaben der Ethikbeauftragten dargestellt. Zudem wird das Qualifikationsprogramm für Ethikbeauftragte (Basis- und Aufbauschulung) sowie ein Train-the-Trainer-Konzept vorgestellt, welche eine vertiefende Entwicklung von pflege- und medizinethischer Kompetenzen unterstützen und Sicherheit in den stationsbezogenen Reflexions- und Entscheidungsprozessen vermitteln.
Article
Background: The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses. Purpose: To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey. Methods: A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020. Findings: A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress. Implications for practice: NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses. Implications for research: Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.
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Background and Objectives Primary care providers (PCPs) report decreased job satisfaction and high levels of burnout, yet little is known about their experience of moral distress. The aim of this study was to gain insight into the experiences of PCPs regarding moral distress including causative factors and proposed mitigation strategies.Methods This qualitative pilot study used semi-structured interviews to identify causes of moral distress in PCPs in an academic family medicine department. Interviews were analyzed using conventional content analysis.ResultsOf 35 eligible participants, 12 completed the study (34% participation rate). Most were white, female, and had practiced for less than 10 years. Four PCPs had considered leaving their position due to moral distress. Participants identified five causes of moral distress: policies and procedures that conflict with patient needs, the unpredictable nature of primary care, need to “bend the rules,” lack of accountability, and lack of support staff. Six internal conflicts made resolving morally distressing situations difficult: perceived powerlessness, sense of responsibility, socialization to follow orders, emotional toll of the job, competing obligations, and fear of mistakes.Conclusions These findings matched themes in the current literature and identified an unbending infrastructure. This, coupled with the chaotic nature of primary care, resulted in frequent moral distress. Participants offered solutions to reduce and mitigate moral distress (also similar with current literature) and suggested moral distress and burnout are closely linked.
Article
Background Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. Materials and methods This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. Results 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. Conclusions Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.
Article
Moral distress occurs when one knows a morally correct action to take but feels powerless to act the way one believes is right. Moral distress has been studied in many contexts but there remains a gap in our understanding of the phenomenon as it manifests outside of hospital‐based settings. The aim of this study was to explore the nature of the moral distress experience among community‐based health and social care professionals working with older adults and their caregivers. Using a qualitative constructionist design, we interviewed 24 participants from a single health authority in southwestern Ontario, Canada. Participants were both urban and rurally based. Data were collected in the winter and summer of 2020 and analysed using Braun and Clarke's thematic analysis strategy. Three factors: reluctant clients, human resource shortages and system challenges, contributed to the creation of perceived morally precarious care plans, resulting in symptoms of moral distress. Study participants described frustration, guilt, anger, and grief at not being able to act consistently with their core values and provide the amount and/or quality of care their clients and unpaid caregivers deserved. We consider possible reasons for our finding that community service providers did not always respond to the consequences of moral distress symptoms in a manner similar to those in acute care contexts. Our findings suggest that study participants may have been able to cultivate moral resilience in the face of moral distress through the positive reframing of adversity and therefore maintain their overall sense of moral integrity.
Article
Moral distress is the phenomenon whereby healthcare providers experience the inability to take action or act in morally appropriate ways when encountering a morally compromising situation. The correlation of moral distress to burnout and resignation in nursing and other healthcare fields has led to increasing attention and concern among healthcare professionals to identify the sources of moral distress, as well as find ways to alleviate it. An online mix-method survey was sent to NSGC members to gain information on (1) sources of moral distress, (2) emotions involved, (3) coping strategies, and (4) suggestions to alleviate it. The ProQOL 5 scale was included to measure genetic counselor compassion satisfaction, burnout, and secondary traumatic stress. Two hundred and thirteen genetic counselors from North America completed the survey. Forty-eight percent of respondents experienced moral distress and five sources were identified. The sources were situations involving other providers, family members, professional responsibility, personal beliefs, and access. Those more likely to experience moral distress worked in a prenatal setting, were over the age of 50, and worked for more than 21 years. Genetic counselors were more likely to talk to a co-worker for support, and seek social support, address the source of the problem, and sustain self through working with patients as coping strategies. Most genetic counselors recommended talking to another genetic counselor to alleviate moral distress. Moral distress did not correlate with genetic counselor burnout, but did correlate with higher levels of secondary traumatic stress (p < 0.01). Thirty-two percent of genetic counselors considered leaving their specialty, and 23% considered leaving their profession based on their experience(s) with moral distress. Our study establishes the existence of moral distress in the genetic counseling field and supports the need for coping strategies and recommendations in order to alleviate future genetic counselor moral distress.
Chapter
This chapter introduces complexity science as a framework for understanding the healthcare delivery system and the inherent challenges it poses for healthcare providers. The Institute for Healthcare Improvement's triple aim, which focuses on the patient experience, population health, and decreased costs, served the health disciplines for a short period of time. It was then recognized that the healthcare provider, the worker at the point of care, was instrumental in the success of the triple aim. This concept, the health and wellbeing of the worker, came to be crystallized as meaning and joy in one's work. The chapter explores this positive affect concept as well as that of compassion satisfaction along with negative affect occupational-based strains occurring for the healthcare provider as they navigate working in the complex healthcare delivery system of the United States.
Article
Aim: This study aimed to evaluate an ethics education program developed to increase moral efficacy among nurses in an acute health-care facility. Background: Moral distress among nurses can cause serious problems in terms of hospital organizations and patient safety. To reduce moral distress and promote professional confidence in nursing practice, a strategic intervention program is needed. Methods: An ethics education program introduced methods to increase self-efficacy in accordance with Bandura's social cognitive theory. Eight nurses were recruited from 2017 to 2019 and all conversations and discussions regarding the ethics consultation were recorded on IC recorders and analyzed qualitatively. Results: Four core categories-Convinced to take an active role in ethical issues; Progressed in nursing practice with ethical agency; Experienced professional transformation; and Empowered by the presence of colleagues-emerged as outcomes of the ethics education program that related to moral efficacy. Conclusions: The four core outcome categories suggested that the participants had gained confidence after taking part in the ethical education program. Implications for nursing management: The results of the participants' described behaviors and actions suggested that they would be proactive in contributing to reductions in moral distress in the future.
Article
Résumé Dès les premières semaines de l’épidémie de la Covid-19, en France, plusieurs voix se sont levées pour dire que l’heure n’était pas à la réflexion éthique, mais à l’action, en soulignant néanmoins l’importance d’un retour d’expérience à l’issue de l’urgence. Dans cette visée, le Centre d’éthique clinique de l’AP–HP a proposé, dès la fin du 1er confinement national, à des soignants, comme à des patients ou à des proches, de revenir, s’ils le souhaitaient, sur les questionnements ou les difficultés éthiques rencontrées pendant cette période (ce qu’il a appelé des « relectures éthiques »). Entre mai et septembre 2020, 31 professionnels y ont participé, 1 seul patient (médecin à la retraite) a été rencontré et aucun proche. Cet article souhaite partager la façon dont ces professionnels sont revenus, dans l’après-coup, sur les premiers mois de la crise. Plus d’une année plus tard, à l’heure où ce qui était « inhabituel » commence par devenir « ordinaire », et le « retour à la vie normale » semble à l’horizon, il n’est pas inutile de rappeler leurs réactions, leurs interrogations et leurs malaises. Au croisement des entretiens, c’est un questionnement quant à ce que soigner veut dire aujourd’hui et au rôle de la médecine en contexte de crise que l’on voit émerger.
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Introduction During their practice, nurses regularly encounter clinical ethical situations. As part of a graduate clinical ethics course, nurses had to write a narrative descriptions of a situation they experienced. Their descriptions seemed to include several considerations related to their occupational health and safety (OHS). This research aimed to highlight the sources of ethical situations and to explore these OHS considerations. Methods In all, 115 narrative descriptions, written by nurses during this course, were analyzed by using a continuous comparison technique (thematic analysis). Results The sources of the situations are described using two components: substance and subject. The substance of the situation (dilemma, breach or disagreement) is defined along two continua: certainty/uncertainty and acceptability/unacceptability. The first continuum reflects the nurse's stance concerning the best option to choose in the situation. The second continuum relates to whether the options discussed in the situation are, in the nurse's opinion, acceptable or unacceptable. As for the subject of the situations, it relates to principles, rights or occupational safety and health determinants. This provides a much broader picture of the ethical situations faced by nurses. The majority of these described situations has underlying dynamics related to OSH. Conclusion In each situation described, the interplay between the substances and subject is promising because it allows to describe and distinguish what the situation was about and the way that subject led to the problem. This comprehension of the sources also emphasizes that OSH aspects could have a significant impact on ethical situations experienced by nurses. Consequently, developing ethical competency should take these aspects into account and not be focused solely on the patient and the care.
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Aufgrund der COVID-Pandemie-bedingten Veränderungen sind Pflegende im Setting der stationären Altenpflege besonderen Belastungen ausgesetzt und können in Bezug auf ihre moralische Verantwortung Dilemmata erleben. Ziel dieser Untersuchung ist es, die Auswirkungen und Wahrnehmungen hinsichtlich der Entstehung von Moral distress von Pflegenden im Setting der Altenpflege während der SARS-CoV-2-Pandemie in Deutschland zu explizieren und daraus Schlussfolgerungen für die Gestaltung von Pflege in stationären Pflegeeinrichtungen zu ziehen. Auf der Basis einer Subgruppenanalyse (n= 510) des qualitativen Surveys der COVID-19-Pflegestudie werden Wahrnehmungen von Altenpflegenden während der Pandemie in Deutschland dargestellt und hinsichtlich der Entwicklung von Moral distress ausgewertet. Durch die Analyse können 5 Kategorien („Dass wir keine Zeit haben, um ordentlich pflegen zu können“, „Vereinsamung“, „Konflikte mit Angehörigen und Bewohnern“, „Ständige Angst um Patientensicherheit, aber auch um die eigene Sicherheit“ und „Trauer, Stress undWut“) identifiziert werden, die differenzierte Kriterien zum Entstehen von Moral distress bei den Altenpflegenden sowie deren Auswirkungen darlegen. Aus den Erkenntnissen ist zu schlussfolgern, dass strukturelle und fachliche Lösungen entwickelt werden müssen, die es Pflegenden ermöglichen, ihr eigenes Arbeitsumfeld zu gestalten und fachliche Versorgungsentscheidungen selbstständig zu übernehmen.
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The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused an unprecedented public health crisis with challenges that can be categorized as operational, technological, knowledge-based, and ethical. The ethical challenge for trainees has been the abrupt transition from patient-centered ethics to public health ethics. This chapter will explore the impact of the COVID-19 pandemic on the surgical residency construct, the residency “life cycle”, and the individual resident as a member of the surgical workforce, as a trainee, and their personal well-being.
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Problem Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. Background Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. Aim To explore Australian midwives experience and consequences of moral distress. Methods Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. Findings Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. Discussion It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. Conclusion This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.
Article
"מועקה מוסרית" הוא מושג המתאר תופעה רגשית, קוגניטיבית ופיזית המלווה מטפלים בעת הימצאות בצומת שבין פעולה שלהערכתם "נכון" לבצע ובין זו שלהבנתם "אפשר" לבצע בתוך מערכת של שיקולים אישיים, מקצועיים וארגוניים התופעה נחקרה בהרחבה בקרב מטפלים ממקצועות הרפואה והסיעוד, אבל אף שהיא נפוצה בקרב פיזיותרפיסטים, בעלת מקורות שונים ומשמעויות והשלכות רבות, היא לא נחקרה עד היום בהרחבה באוכלוסייה זו. המחקר בחן מועקה מוסרית בקרב פיזיותרפיסטים בישראל בשיטה מעורבת-לינארית: בשלב הראשון נערך מחקר כמותי שבדק מודל תיאורטי רב-גורמי שנועד להסביר את התופעה, לאחריו, ועל בסיס ממצאיו, נערך מחקר איכותני במטרה להעמיק את ההבנה של התופעה דרך החוויות, התפיסות והפרשנויות של פיזיותרפיסטים.
Article
Child welfare (CW) professionals who provide direct services to families, referred to as ‘caseworkers’ in the USA, often have to act in ways that are inconsistent with their professional values, leading to feelings of guilt, anxiety and self-blame, referred to as moral distress. The conceptual basis for moral distress primarily comes from the nursing literature, leaving a theoretical gap in how CW workers experience moral distress. Hence, this study used qualitative system dynamics modelling to develop a dynamic theory of moral distress amongst US CW caseworkers (N = 25 focus groups, 192 participants). Results, presented in a qualitative system dynamics model, reveal that participants held strong values pertaining to CW casework and that moral distress was common. Participants described discrepancies between the services they wanted to provide and the services they were actually providing, and the distressing feelings that resulted. Study findings also highlight coping strategies and ‘breaking points’ related to moral distress. Overall, this study’s dynamic theory provides a framework that illustrates the stock (accumulation) and flow (release) of moral distress specific to CW caseworkers and sheds light on the psychological distress and conflict experienced in this profession. Implications for social work education and CW organizational change are discussed.
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The COVID‐19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID‐19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to consider needs for additional support. Twenty semi‐structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges.
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The epidemic of burnout illuminates a public health crisis within medicine, and in oncology, with noteworthy ethical implications for sustaining the workforce. Physicians report increased time and responsibility dedicated to electronic record documentation, patient quotas, and administrative tasks that compromise their personal and professional values, physician-patient relationship, and the provision of quality, ethical care. These tasks contribute to burnout and moral distress resulting in consequences including anxiety, depression, substance abuse, and a demoralized workforce. From an ethical perspective, the physician-patient relationship will only be sustained if the medical community deliberately prioritizes physician well-being. Efforts dedicated to fostering resilience and professional fulfillment are critical. Workforce sustainability is an organizational moral imperative that ultimately advances care. Leadership has a fiduciary duty to recognize burnout and its ethical impact on overall well-being; proactively engage leaders and physicians in collaborative action planning; and improve practice environment and culture.
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Being a healthcare professional in both paediatric and adult hospitals will mean being exposed to human tragedies and stressful events involving conflict, misunderstanding, and moral distress. There are a number of different structured approaches to reflection and discussion designed to support healthcare professionals process and make sense of their feelings and experiences and to mitigate against direct and vicarious trauma. In this paper, we draw from our experience in a large children’s hospital and more broadly from the literature to identify and analyse four established approaches to facilitated reflective discussions. Each of the four approaches seeks to acknowledge the stressful nature of health professional work and to support clinicians from all healthcare professions to develop sustainable skills so they continue to grow and thrive as health professionals. Each approach also has the potential to open up feelings of uncertainty, frustration, sorrow, anguish, and moral distress for participants. We argue, therefore, that in order to avoid unintentionally causing harm, a facilitator should have specific skills required to safely lead the discussion and be able to explain the nature, scope, safe application, and limits of each approach. With reference to a hypothetical but realistic clinical case scenario, we discuss the application and key features of each approach, including the goals, underpinning theory, and methods of facilitation.
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Moral distress, initially described as the form of distress that occurs “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action,” is highly prevalent among physicians. Contemporary descriptions of moral distress involve three domains including negative attitudes one experiences, one’s perceived involvement in a situation, and perceived moral undesirability of the situation. Common sources of moral distress stem from clinical situations and internal and external constraints. Interventions can be targeted at the root causes and components of moral injury and distress, on both individual and organizational levels. These include fostering resiliency in individual clinicians, providing support and moral leadership and ethical culture. This chapter will provide an overview of moral distress in physicians including definitions, common sources and constraints, as well as interventions with specific examples from oncology and the COVID-19 pandemic.
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Moral distress has received much attention in the international nursing literature in recent years. In this article, we describe the evolution of the concept of moral distress among nursing theorists from its initial delineation by the philosopher Jameton to its subsequent deployment as an umbrella concept describing the impact of moral constraints on health professionals and the patients for whom they care. The article raises worries about the way in which the concept of moral distress has been portrayed in some nursing research and expresses concern about the fact that research, so far, has been largely confined to determining the prevalence of experiences of moral distress among nurses. We conclude by proposing a reconsideration, possible reconstruction and multidisciplinary approach to understanding the experiences of all health professionals who have to make difficult moral judgements and decisions in complex situations.
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Physicians providing end-of-life care are subject to a variety of stresses that may lead to burnout and compassion fatigue at both individual and team levels. Through the story of an oncologist, we discuss the prodromal symptoms and signs leading to burnout and compassion fatigue and present the evidence for prevention. We define and discuss factors that contribute to burnout and compassion fatigue and consider factors that may mitigate burnout. We explore the practice of empathy and discuss an approach for physicians to maximize wellness through self-awareness in the setting of caring for patients with end-stage illness. Finally, we discuss some practical applications of self-care in the workplace.
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The experience of moral distress can be distinguished from the experience of moral dilemmas. In moral distress, a nurse knows the morally right course of action to take, but institutional structure and conflicts with other co-workers create obstacles. A nurse who fails to act in the face of obstacles also may have reactive distress in addition to the initial distress. Both kinds of distress pose dilemmas about individual and collective moral responsibility. Coping with these dilemmas effectively requires taking at least some successful actions to resolve distress.
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During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as "moral distress". The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.
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Nurses' perceptions of futile care may lead to emotional exhaustion. To determine the relationship between critical care nurses' perceptions of futile care and its effect on burnout. A descriptive survey design was used with 60 critical care nurses who worked full-time and had a minimum of 1 year of critical care experience at the 2 participating hospitals (350-470 beds). Subjects completed a survey on demographics, the Moral Distress Scale, and the Maslach Burnout Inventory. Six research questions were tested. The results of the following question are presented: Is there a relationship between frequency of moral distress situations involving futile care and emotional exhaustion? A Pearson product moment correlational analysis indicated a significant positive correlation between the score on the emotional exhaustion subscale of the Maslach Burnout Inventory and the score on the frequency subscale of the Moral Distress Scale. Moral distress accounted for 10% of the variance in emotional exhaustion. Demographic variables of age, education, religion, and rotation between the critical care units were significantly related to the major variables. In critical care nurses, the frequency of moral distress situations that are perceived as futile or nonbeneficial to their patients has a significant relationship to the experience of emotional exhaustion, a main component of burnout.
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The extended role of pharmacists has made pharmacy practice more complex and increased the moral responsibility of pharmacy staff. Consequently, ethics has become an important part of their daily work. In health care, ethical dilemmas have been shown to cause distress, usually referred to as "moral distress". Moral distress among hospital personnel has been well described and discussed in numerous studies. There are very few similar studies in pharmacy settings. This article reports on the results of an investigation concerning whether and in what situations moral distress is present in pharmacy practice. A questionnaire derived from focus group data, covering ethically troubling situations in pharmacy settings, was distributed to all staff of three pharmacies in Sweden. The results show that moral distress is experienced in the day-to-day pharmacy practice, and that it is in many ways connected to care providing. For example, prioritizing between customers was reported as very stressful. Younger personnel reported higher moral distress than their older colleagues did. However, there were no differences between pharmacies. A lack of support structures, such as meetings where ethical issues can be discussed, was reported by all the participating pharmacies. It is reasonable to assume that moral distress is even more present in pharmacy practice than in other health care areas as it is, in general, much more sensitive and exposed to the modern, demanding customer. The meeting with the customer is on a more neutral ground than in, for example, a hospital setting. Although there are ethical codes for pharmacists, they are not enough. Moral distress is experienced anyway; general codes and personal coping strategies must be supplemented with support from the management and work organization. There is a need to look more closely at specific factors related to the degree and extension of moral distress, going beyond individual coping strategies.
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Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making. Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines. A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues. There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.
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Moral distress is caused by situations in which the ethically appropriate course of action is known but cannot be taken. Moral distress is thought to be a serious problem among nurses, particularly those who practice in critical care. It has been associated with job dissatisfaction and loss of nurses from the workplace and the profession. To assess the level of moral distress of nurses in a medical intensive care unit, identify situations that result in high levels of moral distress, explore implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses. A descriptive, questionnaire study was used. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress. Nurses reported a moderate level of moral distress overall. Highest levels of distress were associated with the provision of aggressive care to patients not expected to benefit from that care. Moral distress was significantly correlated with years of nursing experience. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation. Critical care nurses commonly encounter situations that are associated with high levels of moral distress. Experiences of moral distress have implications that extend well beyond job satisfaction and retention. Strategies to mitigate moral distress should be developed and tested.
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Nurse clinicians may experience moral distress when they are unable to translate their moral choices into moral action. The costs of unrelieved moral distress are high; ultimately, as with all unresolved professional conflicts, the quality of patient care suffers. As a systematic process for change, this article offers the AACN's Model to Rise Above Moral Distress, describing four A's: ask, affirm, assess, and act. To help critical care nurses working to address moral distress, the article identifies 11 action steps they can take to develop an ethical practice environment.
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Medical students may find certain clinical experiences particularly difficult. Moral distress occurs when a trainee sees a situation or behavior as undesirable, but, because of a position in the hierarchy, declines to address the problem. To prompt our students to reflect on such experiences, students are required to submit a brief case description and are assigned to mentor groups to discuss cases. After exemption from our Institutional Review Board, a database of student submissions was de-identified. A total of 192 case descriptions were analyzed by a single reviewer to identify recurrent themes. Submissions were categorized in a binary fashion as higher or lower levels of distress. Frequency and correlation with levels of distress were assessed for each theme. Sixty-seven percent of the submissions were classified as higher distress. Seven major themes were identified, the most common being problems of communication (n = 179). Those students taking action correlated to lower distress. Our review shows that specific situations can be expected to generate moral distress in trainees. Addressing such distress may support the ongoing professional growth of trainees.
Article
Moral distress is the knowledge of the ethically appropriate action to take but the inability to act upon it. This phenomenon is one experienced in the critical care setting. To help staff members cope with moral distress, a team conducted workshops at one facility to help the staff identify and cope with this distress. The workshop consisted of discussions of distressing situations in the intensive care unit, didactic information on moral distress, formulation of an individual plan to reduce stress, and strategies to deal with moral distress in the intensive care unit. This article discusses the workshop and its effect on participants' coping with moral distress.
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Constraint of nurses by healthcare organizations, from actions the nurses believe are appropriate, may lead to moral distress. To present findings on moral distress of critical care nurses, using an investigator-developed instrument. An instrument development design using consensus by three expert judges, test-retest reliability, and factor analysis was used. Study participants (N = 111) were members of a chapter of the American Association of Critical-Care Nurses, critical care nurses employed in a large medical center, and critical care nurses from a private hospital. A 32-item instrument included items on prolonging life, performing unnecessary tests and treatments, lying to patients, and incompetent or inadequate treatment by physicians. Three factors were identified using factor analysis after expert consensus on the items: aggressive care, honesty, and action response. Nurses in the private hospital reported significantly greater moral distress on the aggressive care factor than did nurses in the medical center. Nurses not working in intensive care experienced higher levels of moral distress on the aggressive care factor than did nurses working in intensive care. Of the 111 nurses, 12% had left a nursing position primarily because of moral distress. Although the mean scores showed somewhat low levels of moral distress, the range of responses revealed that some nurses experienced high levels of moral distress with the issues. Research is needed on conditions organizations must provide to support the moral integrity of critical care nurses.
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Nursing has a long and rich history of caring for those who are sick and suffering, as well as for those who are dying. The threat of death, and/or the reality of suffering till death, for patients, is a reality in the lives of nurses. The purpose of this study was to examine how nurses live with patients who are suffering and dying. Founded on notions of relationship and embodiment, naturalistic inquiry was used to generate and analyse qualitative data from nine nurses who, at the time of the study, were working with patients whom they described as suffering or dying. Findings reflected how the nurses used the dilemmas of their patients' lives to inform their own personal and professional lives through a process of 'weaving a fabric of moral meaning'. Findings are discussed in terms of practice, research and education.
This paper describes a study of the experiences of seven nurses working with the families of people who die in the Intensive Care Unit (ICU). A phenomenological approach is taken, which is informed by Heidegger and hermeneutics. Van Manen's methodological suggestions are used to shape and focus the study. The findings reveal that ICU nurses recognize this as a particularly difficult and tragic time in people's lives. Nurses are aware that the last hours or days with a dying relative may be vividly remembered for years to come. During this time nurses seek to optimize the human experience of the family by making the time as positive as, or the best, possible. This is achieved through strategies such as Being there, Supporting, Sharing, Involving, Interpreting and Advocating. These strategies are enabled by three domains: Nurse as Person, Nurse as Practitioner and Nurse as Colleague which describe a wider context to working effectively with families rather than merely looking at direct interactions between nurse and family. Optimizing the human experience is proposed as the central essence or phenomenon of nursing the families of people who die in intensive care.
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Purpose: We sought to determine the effects of a communication process that was designed to encourage the use of advanced supportive technology when it is of benefit, but to limit its burdens when it is ineffective. We compared usual care with a proactive, multidisciplinary method of communicating that prospectively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient. This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death. Materials and methods: We performed a before-and-after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care. Multidisciplinary meetings were held within 72 hours of critical care admission. Patients, families, and the critical care team discussed the care plan and the patients' goals and expectations for the outcome of critical care. Clinical "milestones" indicative of recovery were identified with time frames for their occurrence. Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient's goals. We measured length of stay, mortality, and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention. Results: Intensive communication significantly reduced the median length of stay from 4 days (interquartile range, 2 to 11 days) to 3 days (2 to 6 days, P = 0.01 by survival analysis). This reduction remained significant after adjustment for acute physiology and chronic health evaluation (APACHE) 3 score [risk ratio (RR) = 0.81; 95% confidence interval (CI), 0.66 to 0.99; P = 0.04). Subgroup analysis revealed that this reduction occurred in our target group, patients with acuity scores in the highest quartile who died (RR = 0.60; 95% CI, 0.38 to 0.92; P = 0.02). The intervention, which allowed dying patients earlier access to palliative care, was not associated with increased mortality. Conclusions: Intensive communication was associated with a reduction in critical care use by patients who died. Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective.
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Nurs Outlook 2000;48:199-201.
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This methodological research developed and evaluated the moral distress scale from 1994 to 1997. Although nurses confront moral questions in their practice daily, few instruments are available to measure moral concepts. The methodological design used a convenience sample consisted of 214 nurses from several Unites States hospitals. The framework guiding the development of the moral distress scale (MDS) included Jameton's conceptualization of moral distress, House and Rizzo's role conflict theory, and Rokeach's value theory. Items for the MDS were developed from research on the moral problems that nurses confront in hospital practice. The MDS consists of 32 items in a 7-point Likert format; a higher score reflects a higher level of normal distress. Mean scores on each item ranged from 3.9 to 5.5, indicating moderately high levels of moral distress. The item with the highest mean score (M=5.47) was working where the number of staff is so low that care is inadequate. Factor analysis yielded three factors: individual responsibility, not in the patient's best interest, and deception. No demographic or professional variables were related to moral distress. Fifteen percent of the nurses had resigned a position in the past because of moral distress. The results support the reliability and validity of the MDS.
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First, to assess the pattern of the prediction of intensive care unit patients' outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients. Prospective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life. Six-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital. All patients older than 18 yrs, admitted to the medical intensive care unit for >24 hrs over a 1-yr period (December 1997 to November 1998). Daily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission. Data regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed (p <.001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors (p <.001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients' own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given. Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.
Article
Moral distress, a complex human experience, has lacked a clear, complete definition. Intuitively, clinicians know that moral distress might be occurring for patients with increasing frequency due to technological advances that alter the natural order of life and death. Yet clinicians have not been able to evaluate the presence or extent of moral distress. To date, moral distress has been investigated mainly as an occupational issue using Jameton's (1984) definition, which has been problematic for several reasons. Without an adequate definition, moral distress can be unrecognized, yet have a silent, clinically significant impact on health. The literature is discussed from several perspectives to show the current state of the science in this topical area, and its potential future.
Article
This paper will examine the concepts of integrity and moral residue as they relate to nursing practice in the current health care environment. I will begin with my definition and conception of ethical practice, and, based on that, will go on to argue for the importance of recognizing that nurses often find themselves in the position of compromising their moral integrity in order to maintain their self-survival in the hospital or health care environment. I will argue that moral integrity is necessary to a moral life, and is relational in nature. When integrity is threatened, the result is moral distress, moral residue, and in some cases, abandonment of the profession. The solution will require more than teaching bioethics to nursing students and nurses. It will require changes in the health care environment, organizational culture and the education of nurses, with an emphasis on building a moral community as an environment in which to practise ethically.
Article
To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. Journal articles, books, and focus group research findings. Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. The two proposed NANDA diagnoses fill a void in current standardized terminology. It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.
Article
Nurses frequently experience conflict regarding healthcare decisions, yet are expected to implement actions which they perceive to be morally wrong. Research has described the deleterious effects of this moral incongruency, coined moral distress, on nurses' well being and has identified it as a causative agent in nursing turnover, burnout, and nurses leaving the profession. Thus, it is known that moral distress has significant consequences for nurses, but does moral distress affect nurses' provision of care, and if so, how?
Article
The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice.
Article
Nurse clinicians may experience moral distress when they are unable to translate their moral choices into moral action. The costs of unrelieved moral distress are high; ultimately, as with all unresolved professional conflicts, the quality of patient care suffers. As a systematic process for change, this article offers the AACN's Model to Rise Above Moral Distress, describing four A's: ask, affirm, assess, and act. To help critical care nurses working to address moral distress, the article identifies 11 action steps they can take to develop an ethical practice environment.
Article
Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.
Article
To test the reliability and validity of a modified moral distress tool, originally developed for the nursing profession, on respiratory care practitioners. To describe the relationship between moral distress, career dissatisfaction, and job turnover in respiratory care. A 28-question survey was developed. Three categories of survey questions were predefined: "individual responsibility," "not in the patient's best interest," and "deception." Additional questions measured career dissatisfaction, job turnover, and demographic information. University Hospital at the University of Virginia Health System, a 552-bed tertiary care hospital. Fifty-seven of 115 (49.6%) of respiratory care practitioners responded to the survey. Exploratory factor analysis was used to investigate the underlying factor structure. After we extracted theoretically meaningful factors, reliability of each factor was estimated. Multiple regression analysis was conducted to test if the underlying factors predicted career dissatisfaction and job turnover. The factor analysis yielded a five-factor structure. Several questions in the "not in patient's best interest" category scored the highest moral distress including disagreements with surrogate decision makers and providing futile care. Higher scores were also found with questions regarding the perception of unsafe staffing and passively or actively participating in deception. None of the demographic variables predicted career dissatisfaction or job turnover. However, the perception of unsafe staffing was found to be a significant factor in predicting career dissatisfaction and job turnover. In this one-center pilot study, respiratory care practitioners reported experiencing moral distress in many areas of their practice. Distress related to the perception of unsafe staffing may be related to career dissatisfaction and job turnover. Further exploration of the factors that contribute to respiratory care practitioners' moral distress is needed, as well as implementing ways to ameliorate it.
Article
To explore registered nurses' and attending physicians' perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care. Descriptive pilot study using a survey design. Fourteen ICUs in two institutions in different regions of Virginia. Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care. Survey questionnaire. At the first site, registered nurses reported lower collaboration (p<.001), higher moral distress (p<.001), a more negative ethical environment (p<.001), and less satisfaction with quality of care (p=.005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p<.001) and ethical environment (p=.004); for nurses, collaboration was related to satisfaction (p<.001) and ethical climate (p<.001) at both sites and negatively related to moral distress at site 2 (p=.05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p<.001), lower perception of ethical environment (p<.001), and lower perception of collaboration (p<.001). Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.
Article
Is the NICU a morally stressful place to work? If so, is that necessarily a bad thing? According to a study by Janvier et al., the answer to these questions depends less upon the medical conditions of the babies in the NICU and more on the sociocultural milieu of the unit. In units where everybody agrees about the proper approach, there is less moral stress. When people disagree, the workplace is more stressful. Unfortunately, agreement does not necessarily reflect correctness of knowledge or attitudes.
Article
The experience of compassion fatigue is an expected and common response to the professional task of routinely caring for children at the end of life. Symptoms of compassion fatigue often mimic trauma reactions. Implementing strategies that span personal, professional, and organizational domains can help protect health care providers from the damaging effects of compassion fatigue. Providing pediatric palliative care within a constructive and supportive team can help caregivers deal with the relational challenges of compassion fatigue. Finally, any consideration of the toll of providing pediatric palliative care must be balanced with a consideration of the parallel experience of compassion satisfaction.
Article
This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, futility, and the concept of conscientious objection from the perspective of the nurse's potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.
Article
Ethical issues in health care are commonly raised in the media and public consciousness as dramatic and sensational ethical dilemmas. These ethical dilemmas (e.g. abortion, euthanasia, equal access to healthcare) demand attention due to their complexity and the need for public debate, while forming an important part of the context for specific patient situations. In nursing, however, other less easily defined and articulated ethical issues are also occurring moment by moment, filling our daily practice with “an essential moral sense” (1, p. 83). To be a nurse can be seen as seeking to answer the call of a vulnerable patient who is asking for care. Seeking to answer this call is a nursing obligation for it “is always just this encounter with the patient that motivates nurses to take on responsibility” (2, p. 45). When seen in the context of this privileged responsibility, it is not surprising that ethical issues also arise in the encounters between nurses, patients and their families that cannot be described as dilemmas. Ethical issues occur that are embedded in the context of relationships, and issues that revolve around the manner, time and place in which they happen. Precisely because nurses enter into a relationship with patients, and seek to foster their well-being, every aspect of nursing practice becomes morally defined (3). The intimate, finely nuanced nature of nursing relationships means nurses are constantly called upon to “make choices in particular situations that bring about the good” (2, p. 46). It is perhaps for these reasons that the majority of research