No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Moral Distress, Moral Residue, and the Crescendo Effect
... Theoretical discourse relates to the complexity of the term, which encompasses a moral phenomenon, a negative psychological response to this phenomenon (Fourie, 2015), and tension between its ethical and psychological aspects in theoretical discourse (Epstein & Hurst, 2017). Although Jameton's initial definition of moral distress focused on external organisational constraints that limit nurses' ability to adhere to their moral and professional values (Jameton, 1984), later definitions expanded upon these constraints to encompass both external and internal factors (Epstein & Hamric, 2009;Wilkinson, 1988). External constraints in this context might include inadequate staffing, healthcare system hierarchies, lack of collegial relationships, lack of administrative support, policies and priorities that conflict with care needs, compromised care influenced by pressure to reduce costs, and fear of litigation (Epstein & Hamric, 2009;Wilkinson, 1988). ...
... Although Jameton's initial definition of moral distress focused on external organisational constraints that limit nurses' ability to adhere to their moral and professional values (Jameton, 1984), later definitions expanded upon these constraints to encompass both external and internal factors (Epstein & Hamric, 2009;Wilkinson, 1988). External constraints in this context might include inadequate staffing, healthcare system hierarchies, lack of collegial relationships, lack of administrative support, policies and priorities that conflict with care needs, compromised care influenced by pressure to reduce costs, and fear of litigation (Epstein & Hamric, 2009;Wilkinson, 1988). Internal constraints might refer to socialisation to obey orders, futility of past actions, fear of losing jobs, self-doubt and lack of courage, lack of assertiveness, perceived powerlessness, and lack of understanding of the situation (Epstein & Hamric, 2009;Wilkinson, 1988). ...
... External constraints in this context might include inadequate staffing, healthcare system hierarchies, lack of collegial relationships, lack of administrative support, policies and priorities that conflict with care needs, compromised care influenced by pressure to reduce costs, and fear of litigation (Epstein & Hamric, 2009;Wilkinson, 1988). Internal constraints might refer to socialisation to obey orders, futility of past actions, fear of losing jobs, self-doubt and lack of courage, lack of assertiveness, perceived powerlessness, and lack of understanding of the situation (Epstein & Hamric, 2009;Wilkinson, 1988). ...
... Moral residue describes the concept of carrying the distress and unresolved feelings of a morally distressing situation forward into one's moral life, altering one's sense of self [16,17]. Furthermore, repeated exposure to moral distress can result in compounding feelings of moral distress and residue, termed the 'crescendo effect' [18], which can lead a healthcare provider to react more strongly to a similar morally distressing situation the next time it occurs. ...
... Potential consequences of moral distress include burnout [21,22], frustration and anger [23], and an intention to leave one's job [7,20,24,25]. It has been noted, in particular, that the crescendo effect resulting from repeated exposure to moral distress leads to cynicism, detachment, and reduced commitment and integrity [18]. ...
Background
Previous research suggests that moral distress contributes to burnout in nurses and other healthcare workers. We hypothesized that burnout both contributed to moral distress and was amplified by moral distress for hospital workers in the COVID-19 pandemic. This study also aimed to test if moral distress was related to considering leaving one’s job.
Methods
A cohort of 213 hospital workers completed quarterly surveys at six time-points over fifteen months that included validated measures of three dimensions of professional burnout and moral distress. Moral distress was categorized as minimal, medium, or high. Analyses using linear and ordinal regression models tested the association between burnout and other variables at Time 1 (T1), moral distress at Time 3 (T3), and burnout and considering leaving one’s job at Time 6 (T6).
Results
Moral distress was highest in nurses. Job type (nurse (co-efficient 1.99, p < .001); other healthcare professional (co-efficient 1.44, p < .001); non-professional staff with close patient contact (reference group)) and burnout-depersonalization (co-efficient 0.32, p < .001) measured at T1 accounted for an estimated 45% of the variance in moral distress at T3. Moral distress at T3 predicted burnout-depersonalization (Beta = 0.34, p < .001) and burnout-emotional exhaustion (Beta = 0.38, p < .008) at T6, and was significantly associated with considering leaving one’s job or healthcare.
Conclusion
Aspects of burnout that were associated with experiencing greater moral distress occurred both prior to and following moral distress, consistent with the hypotheses that burnout both amplifies moral distress and is increased by moral distress. This potential vicious circle, in addition to an association between moral distress and considering leaving one’s job, suggests that interventions for moral distress may help mitigate a workforce that is both depleted and burdened with burnout.
... According to Kälvemark [6], moral distress occurs when there are dissonances between organisational values and health care professionals' value systems, such as being prevented from giving sufficient care due to institutional constraints [6]. Root causes of moral distress was described, such as having to give compromised patient care, compromised integrity within the team and damaged interactions with patients and their families [7,8]. ...
... A variety of reasons have been found to increase the level of experienced moral distress, such as general workplace distress [16], organisational issues [17], constraints and low staffing [18], insufficient teamwork [17] and poor communication within the team [8]. Studies show that a positive ethical climate [19] and work independence reduce the frequency of moral distress [20]. ...
Background
Moral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one’s values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP).
Methods
Eighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach’s alpha was calculated for each domain and for the scale as a whole.
Results
The scale as a whole showed a Cronbach’s alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ²/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912).
Conclusions
We found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.
... The relationship between moral residue as reactive and recurrent distress, as well as broader issues involving conditions and originating factors of moral distress, has been extensively studied in other works and will, therefore, not be discussed here. See Epstein and Hamric (2009) and ten Have and Patrão Neves (2021), inter alia, for an overview. As a consequence of manifested vulnerability experience(s), i.e. compromised moral integrity and associated moral distress or residue, the vulnerability experience (concerning situational vulnerability) may subsequently be increased, which, in turn, increases the risk of the sustained violation of moral integrity. ...
... This observation suggests overlaps with the "crescendo effect", which Epstein and Hamric (2009) ...
Background
Both vulnerability and integrity represent action‐guiding concepts in nursing practice. However, they are primarily discussed regarding patients—not nurses—and considered independently from rather than in relation to each other.
Aim
The aim of this paper is to characterize the moral dimension of nurses' vulnerability and integrity, specify the concepts' relationship in nurses' clinical practice and, ultimately, allow a more fine‐grained understanding.
Design
This discursive paper demonstrates how vulnerability and integrity relate to each other in nursing practice and carves out which types of vulnerability pose a threat to nurses' moral integrity. The concept of vulnerability developed by Mackenzie et al. (2014) is applied to the situation of nurses and expanded to include the concept of moral integrity according to Hardingham (2004). Four scenarios are used to demonstrate where and how nurses' vulnerabilities become particularly apparent in clinical practice. This leads to a cross‐case discussion, in which the vulnerabilities identified are examined against the background of moral integrity and the relationship between the two concepts is determined in more detail.
Results and Conclusion
Vulnerability and integrity do not only form a conceptual pair but also represent complementary moral concepts. Their joint consideration has both a theoretical and practical added value. It is shown that only specific forms of vulnerability pose a threat to moral integrity and the vulnerability–integrity relationship is mediated via moral distress.
Implications for the Profession and/or Patient Care
The manuscript provides guidance on how the concrete threat(s) to integrity can be buffered and moral resilience can be promoted. Different types of threats also weigh differently and require specific approaches to assess and handle them at the micro‐, meso‐ and macro‐level of the healthcare system.
... They maintain that MI captures the cumulative and lasting effect of routine moral stressors in a way that related constructs, namely burnout and moral distress (MD), cannot (Dean et al., 2019). Others have noted that daily or recurring moral stressors can produce a residue that builds over timea 'crescendo effect'and can lead to MI (Epstein & Hamric, 2009). Further, MI encompasses the existential and spiritual perceptions associated with moral transgressions, which are typically not captured by definitions of MD. ...
... Further, MI encompasses the existential and spiritual perceptions associated with moral transgressions, which are typically not captured by definitions of MD. MD, which arises when institutional constraints make it nearly impossible for an individual to pursue what they know to be the right course of action (Jameton, cited in Epstein & Hamric, 2009), puts emphasis on situational aspects (British Medical Association, 2021). MD is also less concerned with the manifestation of moral emotions such as guilt and shame, which are a foundation of MI (Drescher et al., 2011;Litz & Maguen, 2012;Molendijk, 2018a), and with the erosion of self-concept and worldview (Jamieson et al., 2020). ...
Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.
Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.
Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.
Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.
Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.
... It can cause much damage over time, especially when a person is repeatedly exposed to morally distressing events. Nurses may be exposed to a 'crescendo effect' phenomenon [11]. Indeed, repeated exposure that accumulates over time can affect the moral conscience of professionals, causing great distress and putting future actions at risk. ...
... The feelings and emotions related to the students' experience of M.D. were negative: feelings of helplessness, anger, anxiety, confusion, and frustration accompanied the participants even after some time, underlining the long-term impact of their experiences of discomfort. This could mean that students could become nurses who will manifest an early M.D. residual [1], resulting in a moral residue [11]. This could generate the crescendo effect, which would lead to young nurses being very dissatisfied with their work and even leaving the profession a few years after starting it [40]. ...
Background:
Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress. The same applies to nursing students. This study aims to analyze episodes of moral distress experienced by nursing students during end-of-life care of onco-hematologic patients in hospital settings.
Methods:
This study was conducted in the interpretative paradigm using a hermeneutic phenomenological approach and data were analyzed following the principles of the Interpretative Phenomenological Analysis.
Results:
Seventeen participants were included in the study. The research team identified eight themes: causes of moral distress; factors that worsen or influence the experience of moral distress; feelings and emotions in morally distressing events; morally distressing events and consultation; strategies to cope with moral distress; recovering from morally distressing events; end-of-life accompaniment; internship clinical training, and nursing curriculum.
Conclusions:
Moral distress is often related to poor communication or lack of communication between health care professionals and patients or relatives and to the inability to satisfy patients' last needs and wants. Further studies are necessary to examine the quantitative dimension of moral distress in nursing students. Students frequently experience moral distress in the onco-hematological setting.
... Moral distress arises under circumstances in which "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" [12]. In healthcare, this concept is clarified by the notion that "in morally conflicting situations, the commitment to professional values and experiencing meaning in all patient care is threatened" [13]; encompassing risk factors related to the patient, the health workers, and the institution/system [14]. In the U.S.A., 52.7% to 87.8% of 2579 health workers providing care to patients with COVID-19 (42% nurses), reported initial moral distress related to the fear of infecting others, the negative impact on family, and concerns related to work [15]. ...
... Similar results were obtained in this study, ratings on moral distress decreased over time, while ratings on moral injury remained the same, reflecting psychological harm [62]. The two studies support that, after sustained morally distressing situations, their effect increase over time [14]. ...
In addition to the sanitary constrains implemented due to the pandemic, frontline physicians have faced increased workloads with insufficient resources, and the responsibility to make extraordinary clinical decisions. In 108 physicians who were at the forefront of care of patients with COVID-19 during the first two years of the pandemic, mental health, moral distress, and moral injury were assessed twice, in between two late waves of COVID-19 contagions, according to their adverse psychological reactions, in-hospital experience, sick leave due to COVID-19, quality of sleep, moral sensitivity, clinical empathy, resilience, and sense of coherence. Three months after the wave of contagions, the adverse emotional reactions and moral distress decreased, while moral injury persisted. Moral distress was related to clinical empathy, with influence from burnout and sick leave due to COVID-19, and moral injury was related to the sense of coherence, while recovery from moral distress was related to resilience. The results suggest that measures to prevent physician infection, as well as strengthening resilience and a sense of coherence, may be helpful to prevent persistent mental damage after exposure to a sanitary crisis.
... A resolved situation results in satisfaction, personal growth and flourishing of agents, since they learned to surmount a profound moral difficulty and made sure their valuations were considered (Pekarsky, 1990;Racine, 2016). Conversely, an unresolved situation elicits dissatisfaction attesting to a remaining moral problem (Epstein & Hamric, 2009;Racine, 2022). ...
Rare diseases, defined as having a prevalence inferior to 1/2000, are poorly understood scientifically and medically. Appropriate diagnoses and treatments are scarce, adding to the burden of living with chronic medical conditions. The moral significance of rare disease experiences is often overlooked in qualitative studies conducted with adults living with rare diseases. The concept of morally problematic situations arising from pragmatist ethics shows promise in understanding these experiences. The objectives of this study were to (1) acquire an in-depth understanding of morally problematic situations experienced by adults living with rare diseases in the province of Québec and (2) to develop an integrative model of the concept of morally problematic situations. To this end, an online survey targeting this population was developed through a participatory action research project. Respondents provided 90 long testimonies on the most important morally problematic situations they faced, often in healthcare settings. An integrative model was developed based on various qualitative analyses of these testimonies and relevant literature. The integrative model showcases that morally problematic situations have causes (i.e., contextual and relational factors, personal factors, jeopardized valuations), have affective repercussions (i.e., emotions and feelings, internal tensions), prompt action (i.e., through empowerment strategies leading to the evolution of situations), and elicit outcomes (i.e., factual consequences, residual emotions and feelings, positive or negative resolutions). In sum, this study advances understanding of the moral experiences of adults living with rare diseases while proposing a comprehensive conceptual tool to guide future empirical bioethics research on moral experiences.
... Sin embargo, también influyen factores internos, como el miedo o la falta de conocimientos (McCarthy & Gastmans, 2015). Por lo tanto, el sello distintivo del estrés moral es la presencia de barreras internas o externas que impiden que uno tome las acciones que percibe como moralmente correctas (Epstein & Hamric, 2009;McCarthy & Gastmans, 2015). ...
Introduction: The use of physical restraints is a common practice in the care of hospitalized and institutionalized elderly. However, this practice is currently being questioned because of the physical, psychological, moral, ethical, legal and social repercussions that its use entails. The use of physical restraints is influenced by both the patient himself and his family, as well as the health professionals and the institution. Specifically, the literature indicates that professionals show a lack of knowledge regarding physical restraints and have attitudes favourable to their use, which is related to a worse practice.
Theoretical framework: The study is framed in the critical-social paradigm. Specifically, it has been decided to use Foucault's theoretical framework, especially, the conceptual framework related to safety, discipline, normalization, and resistance. The theory of Haslam's dehumanization has been chosen as a middle-range theory, meaning dehumanizing the act of stripping the person of certain qualities that are characteristic of humans.
Objectives: To explore the culture of physical restraint of geriatric patients among health professionals of intermediate care hospitals in Mallorca. Specifically, it is intended to describe the knowledge, attitudes and practices of professionals regarding the use of physical restraints, to describe the institutional factors that influence it and to analyse its ethical impact, identifying the similarities and differences in the discourse of healthcare professionals according to their discipline and professional category.
Methodology: Qualitative design with an ethnomethodological approach through critical discourse analysis. The study was conducted in intermediate care hospitals in Mallorca. Twenty-two semi-structured interviews were conducted with physicians, nurses, and nursing assistants, selected through theoretical-intentional sampling. Methodological rigour was guaranteed through data saturation, triangulation, and reflexivity.
The study was approved by the Research Commission of the centres included and was positively evaluated by the Research Ethics Committee of the Balearic Islands (IB 4026/19 PI). All participants gave their informed consent and their data were treated confidentially.
Results: The professionals have a lack of knowledge about physical restraints, the legal framework that regulates them and the principles of care without restraints. The restraints are valued as necessary, protective, and even therapeutic elements in the care of the elderly and constitute a standardized practice when they are used in an automated, routine, preventive, and prolonged manner. In addition, architectural and institutional deficits encourage their use, which is maintained due to the lack of control by the organization over its application. The practice of restraint responds thus to the culture of safety and discipline in health institutions and to a dehumanized view of the elderly. Professionals present ethical conflicts arising from the debate between patient autonomy and non-maleficence (understood only from the physical sphere). To deal with these conflicts, professionals deploy strategies such as rationalization based on physical security or their professional role. The practice of physical restraint differs depending on the professional category, in such a way that nursing assistants assume a technical function; nurses prescribe and coordinate the process; and doctors become legal guarantors of the prescription.
Conclusions: Physical restraint is a standardized, dehumanizing, and dehumanized practice in the care of the elderly, justified by and for the geriatric patient's physical security and developed in the presence of a permissive attitude of the institutions. Professionals and institutions must commit to person centred care and free from physical restraints.
Key words: Physical restraints; Health Knowledge, Attitudes, Practice; Organizational culture; Health Personnel; Aged; Hospitalization; Professional ethics; Qualitative research.
... This can negatively impact patient care, increase burnout rates, and prompt nurses to leave their institution or even the nursing profession completely (Cavaliere et al., 2010;Hamric and Blackhall, 2007;Laabs, 2005;Corley, 1995;Wilkinson, 1987). 'Moral residue' occurs when moral distress goes unacknowledged and the accompanying emotions are not adequately addressed, leading to a build-up of frustration and further distress (Epstein and Hamric, 2009). Webster and Bayliss (2000) further elaborated on this concept of moral residue, describing it as the lingering feeling that an individual bears the burden of situations in which they have substantially compromised their principles or allowed themselves to be compromised. ...
Objectives:
The review aims to synthesize and consolidate the factors and situations in which student nurses experience moral distress during their clinical practice and its potential implications for patient care and outcomes.
Design:
A qualitative systematic review.
Data sources:
The articles were sourced from PubMed, Embase, CINAHL, Scopus, PsycInfo, Web of Science, ERIC (ProQuest), and ProQuest Dissertations and Theses Global Database between their inception dates to December 2022. Reference lists of included studies were also screened for additional studies.
Review methods:
Published and unpublished primary studies of any qualitative research methods focused on student nurses' experiences of moral distress regardless of their education level were included in this review. Two reviewers independently screened titles and abstracts, assessed full-text articles for eligibility, extracted data, and appraised the quality of included studies. Sandelowski and Barroso's (2007) two-step meta-synthesis approach and Braun and Clarke's (2006) thematic analysis framework were used to analyze and interpret findings from included studies.
Results:
Seven studies met the inclusion criteria and were included in the review. The meta-synthesis revealed an overarching theme, "Moral Distress and its Intertwined Roots". This was supported by the four main themes: 1) Inadequacy and lack of autonomy, 2) Unprofessionalism of healthcare professionals, 3) Differing cultural views and values of patients and their relatives, and 4) Healthcare needs versus resource constraints.
Conclusion:
This review highlights the experiences of student nurses in situations of moral distress, including feelings of inadequacy and powerlessness when faced with ethical challenges, and the negative impact of resource constraints, unprofessional behavior, and cultural differences. Collaborative efforts between healthcare professionals and student nurses are needed to promote shared decision-making, prioritize ethical training, and provide culturally sensitive care to address these challenges and ultimately improve patient care.
... La procédure collégiale incluant tous les membres du service semble donc à privilégier non seulement pour l'intérêt du patient qui sera sûr d'être accompagné jusqu'à la fin de sa vie par toute une équipe, mais également pour les soignants eux-mêmes qui seront assurés d'être épaulés dans toutes leurs actions. Nos conclusions appuient les recommandations écrites entre autres par Epstein et Hamric (42). La procédure collégiale de décision permet de prendre une décision comprise et acceptée par tous. ...
... The study assumed that high moral courage would moderate the bias of the various concerns that may accompany the decision to provide PC in their conscious existence, thereby allowing the consideration of the care application. This may be explained by the nature of the hospital professional organization that operates as a totalitarian hierarchical system leaving little room for the personal thoughts of individual employees (10,79). Others have shown that low levels of moral courage in decision-making were associated with defensive medicine (80)(81)(82). ...
Introduction
Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD.
Methods
Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (−1) (palliative) to 3 (aggressive), the sum of which is the “Treatment Approach Score;” and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases.
Results
The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness—agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability—perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring—perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia.
Conclusion
Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.
... Some have conceptualized moral distress more broadly, to encompass anguish or anxiety tied to a sense of threatened integrity in one's work (Carse and Rushton 2018). The concept of moral residue suggests that feelings of moral distress may linger after the initial inciting event of constrained moral judgment, resulting in a chronic condition (Epstein and Hamric 2009). Campbell, Ulrich, and Grady (2016) proposed a broader conceptualization of moral distress that accommodates relatively inchoate forms, including situations in which an individual does not know the morally correct action (moral uncertainty), there may not be a morally correct action (moral dilemma), or the individual is not directly implicated in the action (distress by association) (see also Fourie 2015 and. ...
Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians' professional wellbeing, and offer preliminary pathways for intervention.
... 9(p111) Unaddressed, moral distress can leave a harmful "moral residue" when accrued over time. 10 Such distress has been discussed and examined most often in nurses, but there is a growing recognition that moral distress is experienced by many clinicians in a variety of health care roles. 11 Caring and dedicated clinicians, often drawn to the profession by their compassion and desire to heal, can sense a loss of their own humanity and may experience despair when expected to provide potentially inappropriate treatment. ...
... Nursing alone cannot change the work environment. Multiple views and collaboration of the all health care team are needed to improve a system, especially a complex one, such as what is present in a critical care environment (12,27) . ...
Background: Moral distress has been identified as a major factor influencing the physical and emotional well being of the nurses. It is a serious problem among critical care nurses, it my make the nurses avoid the patient and do not act as an advocate. While its impact on the nurses themselves is burnout , resignation from their position, or abandonment of nursing. The impact that moral distress has on the institution is high nurse turnover, low patient satisfaction, and decreased quality of care. The aim of this study was to identify the moral distress related factors affecting the critical care nurses. Method: the study was conducted in six intensive care units (ICUs) of kafr-Elsheikh hospitals. Subjects: All of the critical care nurses providing direct patient's care and working in the mentioned ICUs included in the study (70 nurses). Tool: Moral distress intensity scale was used for data collection, it was adopted from Corely. Results: The physician practice category is found to be the highest moral distress factor followed by the nursing practice category and then the institutional category. Conclusion: Moral distress including several factors is a critical problem that affects the critical care nurses and it needs more attention.
... Moral distress may result in increased fatigue and decreased job satisfaction, higher turnover rates, sick leave and burnout [13][14][15][16][17][18][19]. It may even lead to enduring feelings of shame, regret, self-doubt and guilt [24], also defined as 'moral injury' [25]. Generally, nursing staff have a higher incidence of moral distress than physicians, often attributed to the fact that nurses regularly feel that they are not sufficiently involved in discussions and decision-making processes about ethically complex situations, whilst at the same time having to perform morally critical actions based on decisions made by others [26,27]. ...
Background
The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations.
This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support.
Methods
A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement.
Results
All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’.
Conclusions
Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience.
Trial registration
The trial was registered on The Netherlands Trial Register, number NL9177.
... Pediatric residents are at high risk for moral distress, which is to say the psychological, emotional, and physiologic suffering that clinicians experience when they feel powerless or unable to do what they think is right. [1][2][3][4][5][6][7] Moral distress was first described in a medical setting among nurses for whom autonomy limitations frequently collide with poor communication and leadership. 1 Unsurprisingly, residents, who also work within complicated hierarchies, experience similar feelings as they implement plans without the authority to alter the plans, dissent, or refuse. [8][9][10][11] This predisposes residents to moral distress, particularly when communication and collaboration are weak. ...
Background and objectives:
Pediatric residents are at high risk for moral distress, knowing the moral or ethically right thing to do but feeling unable to do it, which is associated with poor patient care and burnout. Researchers have proposed numerous interventions to reduce distress, but few (if any) have been supported by experimental evidence. In this study, we used an experimental method to provide proof-of-concept evidence regarding the effect of various simple supports on pediatric residents' reported degree of moral distress.
Methods:
We conducted a study of pediatric residents using a split sample experimental design. The questionnaire contained 6 clinical vignettes describing scenarios expected to cause moral distress. For each case, participants were randomly assigned to see 1 of 2 versions that varied only regarding whether they included a supportive statement. After reading each of the 6 cases, participants reported their level of associated moral distress.
Results:
Two hundred and twenty respondents from 5 residency programs completed the experiment. Cases were perceived to represent common scenarios that cause distress for pediatric residents. The addition of a supportive statement reduced moral distress in 4 of the 6 cases.
Conclusions:
In this proof-of-concept study, simple yet effective interventions provided support by offering the resident empathy and shared perspective or responsibility. Interventions that were purely informational were not effective in reducing moral distress.
... Such violation is also considered a major stressor among teachers (Worrall & May, 1989). Fourth, ethically dilemmatic situations constantly repeat themselves, and each of them elevates the existing levels of moral residue, which may lead to a gradual increase in MD levels over time (Epstein & Hamric, 2009). Fifth, there are three levels (in the field of health care professionals) responsible for the occurrence of MD, namely: patient, unit and system (Hamric & Epstein, 2017). ...
Moral distress (MD) is defined as knowing what to do in an ethical situation but being unable to do it. Although this definition was originally meant for healthcare practitioners, it is instantly recognised by those in the teaching profession. This study adopted Q methodology to identify and characterise foreign language teachers’ viewpoints regarding morally distressing situations. Thirty-three teachers of English as a foreign language (EFL) performed a card-sorting task. The sources of MD were characterised into three categories: limited control, violation of personal values and lack of voice. Teachers may be reluctant to pathologise MD because it can arise within everyday scenarios. The findings contribute to the development of supportive strategies in response to various sources of MD.
... It is known that the psychological and emotional responses associated with discomfort or moral distress from ethically wrong actions can increase sometime after the situation [11,12]. These responses include feelings of helplessness, self-blame, anger, frustration, exhaustion, anxiety, and depression [13][14][15]; deterioration in the quality of care and teamwork; and the desire to quit the job [16]. ...
The COVID-19 pandemic has caused ethical challenges and dilemmas in care decisions colliding with nurses' ethical values. This study sought to understand the perceptions and ethical conflicts faced by nurses working on the frontline during the first and second waves of the COVID-19 pandemic and the main coping strategies. A qualitative phenomenological study was carried out following Giorgi's descriptive phenomenological approach. Data were collected through semi-structured interviews until data saturation. The theoretical sample included 14 nurses from inpatient and intensive care units during the first and second waves of the pandemic. An interview script was used to guide the interviews. Data were analyzed following Giorgi's phenomenological method using Atlas-Ti software. Two themes were identified: (1) ethical conflicts on a personal and professional level; and (2) coping strategies (active and autonomous learning, peer support and teamwork, catharsis, focusing on care, accepting the pandemic as just another work situation, forgetting the bad situations, valuing the positive reinforcement, and humanizing the situation). The strong professional commitment, teamwork, humanization of care, and continuous education have helped nurses to deal with ethical conflicts. It is necessary to address ethical conflicts and provide psychological and emotional support for nurses who have experienced personal and professional ethical conflicts during COVID-19.
... To meet the definition of moral distress (components 3 and 4), these interactions must take place in a professional setting and occur repeatedly over time. 24,25 Lastly, it is important to note that moral distress can occur at 3 different levels. 26 Patient-level causes are those that involve a particular patient or client. ...
OBJECTIVE
Assess veterinarians’ reported levels of moral distress and professional well-being. Determine the predictive value of moral distress, controlling for demographic factors, on veterinarians’ levels of Professional Fulfillment, Work Exhaustion, Disengagement, and Burnout.
SAMPLE
Members of the Veterinary Information Network.
PROCEDURES
An electronic survey distributed via the Veterinary Information Network data collection portal.
RESULTS
A total of 1,919 veterinarians completed the survey. For both associates and owners, gender and age were significant predictors of moral distress with younger female veterinarians reporting higher levels of distress than older male veterinarians. For associates, age was a positive predictor and moral distress score was a negative predictor of Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors for Work Exhaustion. For Interpersonal Disengagement and Burnout, age was a negative predictor and moral distress score was a positive predictor. For owners, age was a positive predictor and moral distress score was a negative predictor for Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion, Interpersonal Disengagement, and Burnout.
CLINICAL RELEVANCE
We found that, controlling for age and gender, higher levels of moral distress predicted lower levels of Professional Fulfillment and higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. Given the prevalence of moral distress and its impact on mental health, it is imperative that the veterinary field provide training and education on how to recognize and navigate ethical conflicts.
Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles-2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures-the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.
Background:
Veterinarians may face various ethical decisions and potential moral conflicts in clinical practice. The ethical decision-making process often leads to a satisfying resolution. However, when such a process is accompanied by a perceived inability to act according to a person's values, it can lead to psychological distress that characterises moral distress. Theoretical models in professions such as nursing attempt to explain the evolution of moral conflict into moral distress. In veterinary professionals, a model has been proposed to explain this pathway (the moral deliberation pathway). However, empirical data are still lacking on whether veterinary clinicians experience a moral deliberation pathway as hypothesised.
Methods:
Using thematic analysis, this qualitative study investigates veterinary clinicians' experiences with moral distress and aims to explain the moral deliberation pathway in these veterinarians.
Results:
The results suggest that veterinarians' experiences with moral distress follow a deliberation process that can be explained by the proposed moral deliberation pathway. Experiencing a moral conflict leads to moral stress, then either to moral distress or resolution into moral comfort.
Limitations:
Self-selection of participants and possible recollection bias may have biased the findings.
Conclusions:
The empirical data provided by this study can inform future research and intervention strategies to identify, measure and manage moral distress in the veterinary context.
The use of partial code status in pediatric medicine presents clinicians with unique ethical challenges. The clinical vignette describes the presentation of a pulseless infant with a limited life expectancy. The infant's parents instruct the emergency medicine providers to resuscitate but not to intubate. In an emergency, without a clear understanding of parents' goals, complying with their request risks an ineffective resuscitation. The first commentary focuses on parental grief and how, in certain circumstances, a partial code best serves their needs. Its authors argue that providers are sometimes obligated to endure moral distress. The second commentary focuses on the healthcare team's moral distress and highlights the implications of a relational ethics framework for the case. The commentators emphasize the importance of honest communication and pain management. The final commentary explores the systems-level and how the design of hospital code status orders may contribute to requests for partial codes. They argue systems should discourage partial codes and prohibit resuscitation without intubation.
Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included "moral injury" and "moral distress," identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs.
Problem definition:
Moral distress (MoD) is a vital clinical indicator linked to clinician burnout and provider concerns about declining patient care quality. Yet it is not routinely assessed. Earlier, real-time recognition may better target interventions aimed at alleviating MoD and thereby increase provider well-being and improve patient care quality.
Initial approach and testing:
Combining two validated MoD instruments (the Moral Distress Thermometer [MDT] and the Measure of Moral Distress for Healthcare Professionals [MMD-HP]), the authors developed a novel mobile and Web-based application environment to measure and report levels MoD and their associated causes. This app was tested for basic feasibility and acceptability in two groups: graduate nursing students and practicing critical care nurses.
Results:
The MDT app appears feasible and acceptable for future use. All participants (n = 34) indicated the MDT app was satisfying to use, and 91.2% (n = 31) indicated the app was "very appropriate" for measuring MoD. In addition, 84.2% (n =16) of practicing nurses indicated the app fit either "somewhat well" (47.4%, n = 9) or "very well" (36.8%, n = 7) into their typical workday, and 68.4% (n = 13) said they were either "extremely likely" or "somewhat likely" to use the app daily in clinical practice.
Key insights and next steps:
Education about moral distress and its associated causes proved important to the MDT app's success. It is ready for future validity and reliability testing, as well as examining usability beyond nursing, longitudinal data monitoring, and possible leveraging to pre- and postintervention evaluation studies.
Background:
Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored.
Research aim:
The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses' experience of moral distress, and strategies for coping with moral distress.
Research design:
A descriptive cross-sectional correlational study.
Participants and research context:
A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted.
Ethical considerations:
The study was approved by the institutional review board at the author's affiliated university.
Findings:
Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses' moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively.
Conclusions:
In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance.
Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.
In this chapter, we introduce the concept of moral community and use it as a backdrop for discussion of burnout and moral distress as problems that healthcare organizations as moral communities must address. We focus on moral distress, presenting the state of the science regarding its definition and impact on healthcare providers. Three categories of common causes are provided as are examples of current interventions to address it. In subsequent sections, we outline for educators, students, clinicians, and leaders specific ways to think about moral distress, potential strategies to mitigate it, and rationales for the importance of addressing it in each context. Finally, we provide a sample of future areas for research, acknowledging that the state of the science for moral distress is in its nascent stages and there is much work to be done.KeywordsMoral distressOrganizational ethicsBurnout
Perinatal loss often occurs in the context of discovery of a medical condition that presents patients and healthcare providers (HCPs) with difficult choices. Treatment choices are influenced by medical technology, however inescapable prognostic uncertainty, coupled with shared decision-making can lead to ethical dilemmas (Graf et al., 2023) [1]. When patients experience perinatal loss HCPs must grapple with their own emotions. Their sense of grief arises from their empathic connection with patients, bearing witness to their grief. This grief may compound HCP moral distress. Moral distress has an element of emotion, however it is more than distress in tragic situations. Moral distress is linked to HCPs feeling responsible to take action (Dudzinski, 2016) [2]. In situations of perinatal loss, it is essential to acknowledge the grief and explore how it influences the experience of moral distress. This article will reflect on the impact of HCP grief in ethically complex situation of perinatal loss.
Until the surges of COVID-19 patients overwhelmed our health care system, moral distress was largely unknown outside of health care. We conducted a study in a 36-bed intensive care unit (ICU) over an 8-week period to determine the severity and contributing factors to clinicians' moral distress and how their moral distress impacted intent to leave, and to assess utilization of resources to mitigate the problem. This article describes the level of moral distress experienced by ICU staff, the disparity between hospital-provided resources and the contributing factors of moral distress, and the potential financial cost of job turnover due to moral distress.
We explore the various ethical challenges that arise during the practical implementation of an emergency resource allocation protocol. We argue that to implement an allocation plan in a crisis, a hospital system must complete five tasks: (1) formulate a set of general principles for allocation, (2) apply those principles to the disease at hand to create a concrete protocol, (3) collect the data required to apply the protocol, (4) construct a system to implement triage decisions with those data, and (5) create a system for managing the consequences of implementing the protocol, including the effects on those who must carry out the plan, the medical staff, and the general public. Here we illustrate the complexities of each task and provide tentative solutions, by describing the experiences of the Coronavirus Ethics Response Group, an interdisciplinary team formed to address the ethical issues in pandemic resource planning at the University of Rochester Medical Center. While the plan was never put into operation, the process of preparing for emergency implementation exposed ethical issues that require attention.
Unlabelled:
Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions.
Objectives:
To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress.
Design:
Interview-based qualitative study using inductive thematic analysis.
Setting and participants:
Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians.
Results:
Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians.
Conclusions and relevance:
An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.
Importance:
Moral injury and distress (MID), which occurs when individuals have significant dissonance with their belief system and overwhelming feelings of being powerless to do what is believed to be right, has not been explored in the unique population of military surgeons deployed far forward in active combat settings. Deployed military surgeons provide care to both injured soldiers and civilians under command-driven medical rules of engagement (MROE) in variably resourced settings. This practice setting has no civilian corollary for comparison or current specific tool for measurement.
Objective:
To characterize MID among military surgeons deployed during periods of high casualty volumes through a mixed-methods approach.
Design, setting, and participants:
This qualitative study using convergent mixed methods was performed from May 2020 to October 2020. Participants included US military surgeons who had combat deployments to a far-forward role 2 treatment facility during predefined peak casualty periods in Iraq (2003-2008) and Afghanistan (2009-2012), as identified by purposeful snowball sampling. Data analysis was performed from October 2020 to May 2021.
Main outcomes and measures:
Measure of Moral Distress for Healthcare Professionals (MMD-HP) survey and individual, semistructured interviews were conducted to thematic saturation.
Results:
The total cohort included 20 surgeons (mean [SD] age, 38.1 [5.2] years); 16 (80%) were male, and 16 (80%) had 0 or 1 prior deployment. Deployment locations were Afghanistan (11 surgeons [55%]), Iraq (9 surgeons [45%]), or both locations (3 surgeons [15%]). The mean (SD) MMD-HP score for the surgeons was 104.1 (39.3). The primary thematic domains for MID were distressing outcomes (DO) and MROE. The major subdomains of DO were guilt related to witnessing horrific injuries; treating pregnant women, children, and US soldiers; and second-guessing decisions. The major subdomains for MROE were forced transfer of civilian patients, limited capabilities and resources, inexperience in specialty surgical procedures, and communication with command. Postdeployment manifestations of MID were common and affected sleep, medical practice, and interpersonal relationships.
Conclusions and relevance:
In this qualitative study, MID was ubiquitous in deployed military surgeons. Thematic observations about MID, specifically concerning the domains of DO and MROE, may represent targets for further study to develop an evaluation tool of MID in this population and inform possible programs for identification and mitigation of MID.
Background:
This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic.
Method:
Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews.
Results:
Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for.
Conclusions:
This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.
Aims:
This study aims to develop and examine the effectiveness of a support program for reducing moral distress of nurses, based on the moral case deliberation methodology, and to study the feasibility of its implementation.
Methods:
Study design was an intervention study with pre/post-comparison. The support program included a short lecture and three moral case deliberation sessions for nurses working in an acute care hospital. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) and the Euro-MCD (Moral Case Deliberation) 2.0 scale were used for pre/post-comparison, using the Wilcoxon's signed-rank test. Furthermore, post-intervention interviews were conducted with consenting participants to determine the reasons for changes in pre/post-intervention quantitative data. Of the 34 participants, 29 completed the post-questionnaire and were included in the quantitative data analysis, and 27 were included in the qualitative data analysis.
Results:
The mean MMD-HP total scores increased from 147.5 ± 61.0 to 159.3 ± 66.7, but not significantly (p = .375). The mean score of moral competence, a sub-scale of the Euro-MCD 2.0, increased significantly from 15.4 ± 2.4 to 16.4 ± 2.8 after the intervention (p = .036). A qualitative analysis revealed increased moral sensitivity to ethically difficult situations and improved analytical skills as the reasons for change in scores pre/post-intervention.
Conclusion:
The results of the qualitative analysis suggested the effectiveness of the intervention. The moral distress score increased, although not significantly, and moral competence also increased, suggesting the participants' values changed after the intervention. It was found that the support program using MCD is expected to improve participants' moral competence.
Background:
Moral distress is a damaging experience that impacts adversely on healthcare professional wellbeing, however remains poorly studied in the UK. This study aimed to explore how widespread and severe moral distress is amongst intensive care professionals in the UK.
Methods:
Prior to the COVID-19 pandemic, a paper questionnaire that quantitatively assessed moral distress using the validated Measure of Moral Distress for Healthcare Professionals (MMD-HP) was distributed at four intensive care units of varying size and speciality facilities.
Results:
227 questionnaires were returned, including 165 nurses and 40 doctors with a mean age and ICU experience of 38.1 and 10.1 years, respectively. The median moral distress score was 108 (IQR = 78.2, range 0 to 288). Moral distress was greatest in situations related to delivering aggressive treatment that was perceived as futile or not in the patient’s best interests, closely followed by situations related to lack of resources compromising care. Moral distress was independently influenced by profession (p = 0.02) (nurses 117.0 vs doctors 78.0) and had no relationship with participant age and ICU experience. One-third indicated their intention to leave their current post due to moral distress and this was greater amongst nurses than doctors (37.0% vs 15.0%). Multiple logistic regression models included profession, gender, hospital type, age and ICU experience as covariates and had good discrimination and ability to predict intention to leave. Moral distress was associated with an intention to leave their current post in unadjusted and adjusted analyses (adjOR = 1.011 per 1 unit increase in moral distress, 1.006–1.017, p < 0.0001) and a previous post (adjOR = 1.009, 1.004–1.014, p = 0.001).
Conclusions:
Moral distress appears widespread amongst UK ICU professionals and is worse amongst nurses. Moral distress due to resource-related issues was more severe than comparable studies in North America. Its relationship with an intention to leave a post and the high proportion of ICU nurses considering leaving their current post due to moral distress is concerning, particularly as this study was performed prior to the COVID-19 pandemic. Addressing moral distress should be a priority, however the ideal interventions remain unclear.
Aims:
To gain insight into the world of rural veterinarians during the Mycoplasma bovis incursion within southern Aotearoa New Zealand by exploring their experiences during the incursion, and to understand the consequences, positive and negative, of these experiences.
Methods:
A qualitative social science research methodology, guided by the philosophical paradigm of pragmatism was used to collect data from an information-rich sample (n = 6) of rural veterinarians from Otago and Southland. Interview and focus group techniques were used, both guided by a semi-structured interview guide. Veterinarians were asked a range of questions, including their role within the incursion; whether their involvement had any positive or negative impact for them; and their experience of conflicting demands. Analysis of the narrative data collected was guided by Braun and Clarke's approach to reflexive thematic analysis.
Results and findings:
All six participants approached agreed to participate. Analysis of the data provided an understanding of the trauma they experienced during the incursion. An overarching theme of psychological distress was underpinned by four sub-themes, with epistemic injustice and bearing witness the two sub-themes reported to be associated with the greatest experience of psychological distress. These, along with the other two identified stressors, led to the experience of moral distress, with moral residue and moral injury also experienced by some participants.
Conclusions:
Eradication programmes for exotic diseases in production animals inevitably have an impact on rural veterinarians, in their role working closely with farmers. Potentially, these impacts could be positive, recognising and utilising veterinarians' experience, skills and knowledge base. This study, however, illustrates the significant negative impacts for some rural veterinarians exposed to the recent M. bovis eradication programme in New Zealand, including experiences of moral distress and moral injury. Consequently, this eradication programme resulted in increased stress for study participants. There is a need to consider how the system addresses future exotic disease incursions to better incorporate and utilise the knowledge and skills of the expert workforce of rural veterinarians and to minimise the negative impacts on them.
Clinical relevance:
To date, the experience of moral distress by rural veterinarians during exotic disease incursions has been underreported globally and unexplored in New Zealand. The findings from this study contribute further insights to the existing limited literature and provide guidance on how to reduce the adverse experiences on rural veterinarians during future incursions.
Highlighting the experiences of midwives who provide care to women opting outside of guidelines in the pursuit of physiological birth, Claire Feeley looks at the impact on midwives themselves, and explores how teams and organisations support or discourage women’s birth choices.
This book investigates the processes, experiences and sociocultural-political influences upon midwives who support women’s alternative birthing choice and argues for a shift in perspective from notions of an individual’s professional responsibility to deliver woman-centred care, to a broader, collective responsibility. The book begins by contextualising the importance of quality midwifery care with an exploration of the current debates to demonstrate how hegemonic birth discourse and maternity practices have detrimentally affected physiological birth rates, and the wellbeing of women who opt outside of maternity guidelines. It provides real life examples of how midwives can facilitate a range of birthing decisions within mainstream midwifery services. Moreover, an exploration of midwives’ experiences of delivering such care is presented, revealing deeply polarised accounts from moral injury to job fulfilment. The polarised accounts are then presented within a new model to explore how a midwife’s socio-political working context can significantly mediate or exacerbate the vulnerability, conflict and stigmatisation that they may experience as a result of supporting alternative birth choices. Finally, this book explores the implications of the findings, looking at how team and organisational culture can be developed to better support women and midwives, making recommendations for a systems approach to improving maternity services.
Discussing the invisible nature of midwifery work, what it means to deliver woman-centred care, and the challenges and benefits of doing so, this is a thought-provoking read for all midwives and future midwives. It is also an important contribution to interprofessional concerns around workforce development, sustainability, moral distress and compassion in health and social care.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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
- Epstein E.
- Hanna D.R.