This ethnographic study introduces the term “distressed work” to describe the emergence of chronic frictions between moral imperatives for health care workers to keep working and the dramatic increase in distress during the Covid‐19 pandemic. Interviews and observant participation conducted in a hospital intensive care unit during the Covid‐19 pandemic reveal how health care workers connected job duties with extraordinary emotional, physical, and moral burdens. We explore tensions between perceived obligations of health care professionals and the structural contexts (...) of work. Key findings cluster around the moral imperatives of health care work and the distress that work engendered as work spaces, senses of vocation, patient and family interactions, and end‐of‐life care shifted. While the danger of working beyond limits has long been an ordinary feature of health care work, it has now become a chronic crisis. Assessing this problem in terms of distressed work and its structural contexts can better address effective, worker‐informed responses to current health care labor dilemmas. (shrink)

Background Moral distress is a major issue in intensive care units that requires immediate attention since it can cause nurses to burnout. Given the special conditions of patients in intensive care units and the importance of the mental health of nurses, the present study was designed to systematically review the factors affecting moral distress in nurses working in intensive care units. Methods PubMed, EMBASE, Web of Science, Scopus, and Science Direct were systematically searched for papers published between 2009 and 2019. (...) Original articles from quantitative and qualitative studies were reviewed. The CONSORT and STROBE checklists were used to assess the quality of the quantitative papers. The JBI checklist was applied for qualitative studies. Results Factors affecting moral distress in nurses include lack of nursing staff, nurses with inadequate experience, lack of support from organizations and colleagues, inadequate education and lack of knowledge of nurses, poor collaboration of physicians with nurses, ethical insensitivity and lack of teamwork, heavy workload, poor quality of care and moral violence and they are considered as risk factors for moral distress. Conclusion Many of the related causes are due to the nature of nurses’ work and it is necessary to manage the underlying conditions of this phenomenon so that it can be effectively prevented from spreading. Levels of moral distress require more attention of authorities in the use of prevention strategies and the reduction of effective factors in distress. (shrink)

Public health emergencies, such as the Covid-19 pandemic, put great pressure on healthcare workers (HCW) across the world, possibly increasing the risk of experiencing ethically challenging situations (ECS). Whereas experiencing ECS as a HCW in such situations is likely unavoidable, mitigation of their adverse effects (e.g., moral distress) is necessary to reduce the risk of long-term negative consequences. One possible route of mitigation of these effects is via work environmental factors. The current study aimed to examine: [1] risk factors (...) associated with ECS among HCW [2], intensity of moral distress associated with ECS across various occupational factors (i.e., profession, degree of exposure to patients with Covid-19), and [3] the impact of work environmental factors on this association, in a sample of HCW during the pandemic. We employed multiple logistic and linear regression to self-report data from 977 HCWs at four Norwegian hospitals responding to a survey at the fourth wave of the pandemic. About half of HCW in this study had experienced ECS during the pandemic, and levels of moral distress associated with such were higher than in previous studies using similar assessment methods. Younger age, female sex, geographical work area (mid-north of Norway), and profession (nurse) were all associated with higher odds (range of OR: 1.30–2.59) of experiencing ECS, as were direct contact with patients with Covid-19. Among those participants who reported that they had experienced ECS during the pandemic, moral distress levels when recalling those situations were moderate (Mean 5.7 on a 0–10 scale). Men reported somewhat lower intensity of moral distress (partial eta squared; ηp2 = 0.02). Reporting a manageable workload (ηp2 = 0.02), and greater opportunity to work according to best practice (ηp2 = 0.02), were associated with lower levels of moral distress. Our findings suggest that moral distress could potentially be mitigated on an organizational level, particularly by focusing on ensuring a manageable workload, and an ability to work according to best practice. To build sustainable healthcare systems robust enough to withstand future public health emergencies, healthcare organizations should implement measures to facilitate these aspects of HCWs’ work environment. (shrink)

This study analyses for the first time whether and when moral distress may be related to work-family conflict and burnout. Additionally, this study examines whether resilience and positive refocusing might protect healthcare professionals from the negative effects of moral distress. A total of 153 Italian healthcare professionals completed self-report questionnaires. Simple and moderated mediation models revealed that moral distress was positively related to burnout, directly and indirectly, as mediated by work-family conflict. Highly resilient professionals experienced low work-family (...) conflict, regardless of moral distress levels. Moreover, professionals who frequently used positive refocusing were less vulnerable to burnout following moral distress. (shrink)

The present study investigates the association between diabetes-related distress and work outcomes among employed people with type 1 diabetes. Employed adults with type 1 diabetes completed an online survey. Measures assessed emotional, social, food- and treatment-related DD, burnout, and job satisfaction, as well as the type of insulin treatment. We conducted multiple regression analyses to test our hypotheses. Emotional DD was significantly and positively associated with burnout. Social DD was significantly and negatively associated with job satisfaction. The type of (...) treatment had no significant effect on the outcomes. This study sets the stage for research on the interactions between working conditions, work outcomes and illness symptoms, and problems of people with type 1 diabetes, and, generally, employees with chronic illnesses. The findings have implications for individual health and illness management, burnout prevention, and occupational health measures. (shrink)

Background Emergency nurses who thrive at work experience positive emotions that help reduce burnout and thus enhance career calling. However, few studies have focused on the relationships among thriving at work, career calling, and moral distress among emergency nurses. Objectives To investigate the relationships among thriving at work, career calling, and moral distress and to explore the mediating role of career calling in the relationship between thriving at work and moral distress among emergency nurses. Design A (...) quantitative, cross-sectional study. Methods A cross-sectional study was conducted by reference to 390 emergency nurses in China using an online survey that include the Thriving at Work Scale, the Career Calling Scale, and the Moral Distress Scale-Revised. The data were analyzed using SmartPLS software. Ethical consideration The study was approved by the Ethics Committee of Hunan Normal University (No. 2023-388). Findings Among emergency nurses, thriving at work is positively associated with career calling, while career calling is negatively associated with moral distress. Career calling negatively and completely mediates the relationship between thriving at work and moral distress (β = −0.087, p < 0.01). Discussion Theoretically, the findings enhance our understanding of the relationships among thriving at work, career calling, and moral distress among emergency nurses. Conclusion By emphasizing the benefits of thriving at work, nursing managers can improve nurses’ level of thriving at work by providing a favorable environment, a flexible scheduling system, and appropriate authorization as well as by ensuring organizational fairness and providing training opportunities in a hierarchical manner. (shrink)

This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with (...) moral distress intensity, whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity. (shrink)

Background: Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed. Objective: To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation. Methods: A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. (...) The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale. Results: Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment. Conclusions: Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness. (shrink)

Background: Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress suffered (...) by nurses nor a study conducted on the issue. Aim/objective: The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level. Method: The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale–Revised. Ethical considerations: The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality. Results: In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively. Conclusion: Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care. (shrink)

Background Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as (...) job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. Objectives We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. Research design An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. Participants Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. Research context This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. Ethical considerations The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. Findings Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. Discussion Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. Conclusion This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice. (shrink)

Working memory (WM) is a cognitive system that allows us to select, organise, and integrate perceptual information with memories and current goal-directed intentions. As such, this system is central to day-to-day functioning and would be expected to be especially important in decision making and problem solving. We hypothesised that to the extent that individuals differ in WM capacity they would also be differentially vulnerable to the experience of depression and anxiety. Undergraduate students completed a computerised change detection task in which (...) storage capacity and filtering efficiency measures were obtained. It was found that low WM storage and poor filtering efficiency interacted to predict higher levels of emotional distress as measured by self-reported depressive symptoms, ruminative coping, and state anxiety. It was suggested that low capacity and a poor ability to ignore task-irrelevant information may lead to poorer problem solving, more extreme judgements of oneself and circumstances, increased rumination, and poorer emotional regulation. (shrink)

Background: Moral distress is a very common experience in the nursing profession, and it is one of the main reasons for job dissatisfaction, burnout, and quitting among nurses. For instance, morally difficult situations in taking care of child patients who are severely ill may lead to moral distress for nurses. However, most of the studies about moral distress have been conducted on nurses of special wards and adult medical centers with much focus on developed countries. Subsequently, little has been researched (...) on this topic among nurses in other nations such as Iran, and most certainly, there has been hardly any such research involving Iranian pediatric nurses. Aim/objectives: This study was conducted to evaluate moral distress among nurses in selected pediatric hospitals in Tehran, Iran. Research design: This cross-sectional study was conducted on eligible nurses who were selected through proportional stratified sampling and who completed demographic characteristics and the pediatric version of Moral Distress Scale-Revised questionnaires. Data were analyzed using descriptive statistics, t test, one-way analysis of variance, and Pearson correlation coefficient. Participants and research context: In total, 195 pediatric nurses working at three selected children’s specialized university hospitals in Tehran participated in this study. Ethical considerations: This study was evaluated and approved by the institutional review board of Tehran University of Medical Sciences. Findings: The mean and standard deviation of total score of moral distress was 106.41 ± 61.64 within a range of 10–257. Also, the difference between the mean score of moral distress of the group who had not quitted their position and those who have quit in the past was statistically significant (p = 0.043). The situation that was associated with the highest moral distress was “observing medical students performing painful procedures on patients just to gain some skill.” Total score of moral distress was significantly higher among male nurses (p = 0.014), while nurses with a master’s degree experienced just a higher intensity of moral distress compared to those who had a bachelor’s degree (p = 0.006). Conclusion: Since many pediatric nurses clearly face moral distress while taking care of children, it is necessary to consider measures for preventing or decreasing situations that would lead to this distress. (shrink)

Background: During the COVID-19 pandemic, frontline workers faced a series of challenges balancing family and work responsibilities. These challenges included making decisions about how to reduce COVID-19 exposure to their families while still carrying out their employment duties and caring for their children. We sought to understand how frontline workers made these decisions and how these decisions impacted their experiences.Methods: Between October 2020 and May 2021, we conducted 61 semi-structured interviews in English or Spanish, with individuals who continued to (...) work outside of the home during the pandemic and had children living at home. Interviews were recorded, transcribed verbatim, and analyzed using abductive methods.Results: Frontline workers experienced moral distress, the inability to act in accordance with their values and obligations because of internal or external constraints. Their moral distress was a result of the tensions they felt as workers and parents, which sometimes led them to feel like they had to compromise on either or both responsibilities. Individuals felt morally conflicted because 1) their COVID-19 work exposures presented risk that often jeopardized their family’s health; 2) their work hours often conflicted with their increased childcare responsibilities; and 3) they felt a duty to their colleagues, patients/customers, and communities to continue to show-up to work.Conclusions: Our findings point to a need to expand the concept of moral distress to include the perspectives of frontline workers outside of the healthcare professions and the fraught decisions that workers make outside of work that may impact their moral distress. Expanding the concept of moral distress also allows for a justice-based framing that can focus attention on the disparities inherent in much frontline work and can justify programmatic recommendations, like increasing paid childcare opportunities, to alleviate moral distress. (shrink)

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of (...) the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care. (shrink)

Background: Moral distress is an increasingly documented problem in nursing and might foster nurses’ intention to leave their workplace. It has been studied in different settings, but no specific research has been conducted in Italian correctional facilities. A recent Italian study produced a preliminary validation of the Moral Distress Scale for Correctional Nurses, which needs to be completed. Objectives: To investigate the level of moral distress of nurses working in the Italian correctional setting, by completing the validation process of the (...) Moral Distress Scale for Correctional Nurses. Methodology: Multicenter questionnaire survey. All correctional nurses (461) affiliated with the Italian Society of Medicine and Penitentiary Health (also called “Simspe-onlus”) were invited to participate and 238 responded. The survey was conducted between April and November 2017 through SurveyMonkey®. Analysis of covariance was conducted to investigate the relationship between moral distress and the other variables under study. Exploratory factor analysis was conducted on the scale to confirm its dimensions. Ethical considerations: The study was approved by the Italian Society of Medicine and Penitentiary Health (Simspe-onlus). The questionnaire included informed consent, pursuant to the law in force. The software could not accept questionnaires without explicit consent. Data were analyzed anonymously. Findings: The median score was 46.5, indicating moderate moral distress. The only variable affecting moral distress was work experience in correctional facilities. Longer experience was correlated to higher levels of moral distress and intention to leave. Incompetent colleagues and short staffing were related to higher levels of moral distress. The scale confirmed the one-dimensional structure suggested by the original authors. Discussion: This is the first study investigating moral distress among Correctional Nurses. The prison context is a high-risk environment for nurses, increasing the intention to leave the workplace. Conclusion: Corrective and protective measures, such as specific education, are needed to prevent moral distress development and to reduce nurses’ shortage in this area. (shrink)

Introduction: During their education process, nursing undergraduates experience ethical conflicts and dilemmas that can lead to moral distress. Moral distress can deprive the undergraduates of their working potential and may cause physical and mental health problems. Objective: We investigated the experiences of the undergraduates in order to identify the existence of moral distress caused by ethical conflict and dilemmas experienced during their nursing education. Ethical considerations: This study was designed according to the principles of research with human beings and was (...) approved by the Human Research Ethics Committee. Method: A qualitative multiple-case study. Two federal higher education institutions were surveyed, from which 58 undergraduates in nursing participated in the study. The undergraduates were undergoing their professional training. The data were collected through focus groups and were submitted to thematic content analysis, with the resources of the ATLAS TI 7.0 software. Results: Moral distress in undergraduates is a reality and was identified in three axes of analysis: (1) moral distress is experienced by undergraduates in the reality of healthcare services, (2) the teacher as a source of moral distress, and (3) moral distress as a positive experience. Conclusion: The undergraduates in nursing manifest moral distress in different stages of their education, particularly during their professional training. The academic community should reflect and seek solutions for the reality of moral distress in undergraduates. (shrink)

Background: Moral distress, which is especially high in critical care nurses, has significant negative implications for nurses, patients, organizations, and healthcare as a whole. Aim: A moral distress workshop and follow-up activities were implemented in an intensive care unit in order to decrease levels of moral distress and increase nurses’ perceived comfort and confidence in ethical decision-making. Design: A quality improvement (QI) initiative was conducted using a pre- and post-intervention design. The program consisted of a four-hour interactive workshop, followed by (...) two individual self-reflection activities at 2–3 weeks and 5–6 weeks after the workshop. Participants: Critical care nurses working in a heart and vascular intensive care unit at a large academic medical center. Ethical Considerations: This study was deemed to be a QI project by the institution’s Institutional Review Board. Participation was voluntary. Findings: Nurses experienced a significant decrease in moral distress. The participants’ average ethical confidence increased in four areas (ability to identify the conflicting values at stake, knowing role expectations, feeling prepared to resolved ethical conflict, and being able to do the right thing), with knowledge of role expectations and feeling prepared to resolve ethical conflict yielding statistically significant increases. Qualitative findings resulted in consistent themes related to causes of moral distress and ways nurses approached addressing moral distress. Discussion: This study reinforces previous evidence on moral distress and its causes in critical care nurses, and provides a mechanism for improving moral distress and ethical confidence. Conclusions: This QI study demonstrates the effectiveness of an evidence-based program for decreasing critical care nurses’ moral distress and increasing their ethical confidence. The strategies described in this paper can replicated by nursing leaders who wish to effect change at their local level, or adapted and expanded to other professions and clinical care units. (shrink)

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

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values (...) and responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and (...) PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes. (shrink)

Moral distress is now being recognized as a frequent experience for many health care providers, and there's good evidence that it has a negative impact on the health care work environment. However, contemporary discussions of moral distress have several problems. First, they tend to rely on inadequate characterizations of moral distress. As a result, subsequent investigations regarding the frequency and consequences of moral distress often proceed without a clear understanding of the phenomenon being discussed, and thereby risk substantially misrepresenting (...) the nature, frequency, and possible consequences of moral distress. These discussions also minimize the intrinsically harmful aspects of moral distress. This is a serious omission. Moral distress doesn't just have a negative impact on the health care work environment; it also directly harms the one who experiences it. In this paper, I claim that these problems can be addressed by first clarifying our understanding of moral distress, and then identifying what makes moral distress intrinsically harmful. I begin by identifying three common mistakes that characterizations of moral distress tend to make, and explaining why these mistakes are problematic. Next, I offer an account of moral distress that avoids these mistakes. Then, I defend the claim that moral distress is intrinsically harmful to the subject who experiences it. I conclude by explaining how acknowledging this aspect of moral distress should reshape our discussions about how best to deal with this phenomenon. (shrink)

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

There have been recurrent reports of fragilities in the Brazilian health system, especially in public institutions. In this commentary, I argue that moral distress in nursing in Brazil can still be considered an innovative and important subject of study. I also highlight the relevance of engaging educational institutions in the development of policies about environmental sustainability. It is relevant to continue studying moral distress in nursing and in health care generally in order to contribute to the transformation of reality by (...) confronting the multiple common situations in the work environment that are recognized by many as morally problematic because they infringe upon the rights of people, patients, and health care professionals and are an affront to environmental health. (shrink)

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

Moral distress is a common phenomenon among nurses and is related to the complicated work environments and complex nature of ethical situations in day-to-day nursing practice. Moral distress impacts nurses as well as patient care and the health care system. Few strategies have been identified for instructors to effectively engage with learners when communicating about moral distress. We discuss two key curricular and pedagogical strategies that should be utilized when learning about moral distress: difficult knowledge’ and ‘terror management theory’. (...) Whether it is with new nursing students or experienced nurses, there is necessary learning that needs to occur on moral distress. Difficult knowledge’ and ‘terror management theory’, when implemented, can provide a starting point for both the learner and the instructor to discuss the emotionally difficult and complex topic of moral distress. Knowledge about moral distress has the potential to mitigate its negative effects, therefore it is vital to consider educational strategies to teach nurses about this complex phenomenon. (shrink)

This study was to explore the potential moderating effect of trait forgiveness and its facets on the relationship between perceived work stress and psychological distress among Chinese nursing students in clinical practice. A total of 182 Chinese nursing students who had been receiving final-year clinical training completed self-report measures of nursing work stress, trait forgiveness and psychological distress. Correlation analysis and hierarchical multiple regressions were mainly applied for data analysis. Results showed that trait forgiveness was negatively associated with (...) psychological distress, even after controlling for the effects of perceived work stress and demographic/workplace related variables. Further analyses indicated that the ability to forgiveness of situations was particularly crucial in reducing the negative effects of perceived work stress on psychological well-being, especially when students perceived higher level of stress. These results demonstrated that alternative interventions targeting on trait forgiveness, especially those programs which can improve one’s ability to acceptance uncontrollable bad circumstances, may be beneficial for the well-being of nursing students in clinical practice. (shrink)

Background: COVID-19 pandemic has led to heightened moral distress among healthcare providers. Despite evidence of gendered differences in experiences, there is limited feminist analysis of moral distress. Objectives: To identify types of moral distress among women healthcare providers during the COVID-19 pandemic; to explore how feminist political economy might be integrated into the study of moral distress. Research Design: This research draws on interviews and focus groups, the transcripts of which were analyzed using framework analysis. Research Participants and Context: 88 (...) healthcare providers, based in British Columbia Canada, participated virtually. Ethical Considerations: The study received ethical approval from Simon Fraser University. Findings: Healthcare providers experienced moral dilemmas related to ability to provide quality and compassionate care while maintaining COVID-19 protocols. Moral constraints were exacerbated by staffing shortages and lack of access to PPE. Moral conflicts emerged when women tried to engage decision-makers to improve care, and moral uncertainty resulted from lack of clear and consistent information. At home, women experienced moral constraints related to inability to support children’s education and wellbeing. Moral conflicts related to lack of flexible work environments and moral dilemmas developed between unpaid care responsibilities and COVID-19 risks. Women healthcare providers resisted moral residue and structural constraints by organizing for better working conditions, childcare, and access to PPE, engaging mental health support and drawing on professional pride. Discussion: COVID-19 has led to new and heightened experiences of moral distress among HCP in response to both paid and unpaid care work. While many of the experiences of moral distress at work were not explicitly gendered, implicit gender norms structured moral events. Women HCP had to take it upon themselves to organize, seek out resources, and resist moral residue. Conclusion: A feminist political economy lens illuminates how women healthcare providers faced and resisted a double layering of moral distress during the pandemic. (shrink)

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

Background: Moral distress has been identified as a significant issue in nursing practice for many decades. However, most studies have involved American nurses or Western medicine settings. Cultural differences between Western and non-Western countries might influence the experience of moral distress. Therefore, the literature regarding moral distress experiences among non-Western nurses is in need of review. Aim: The aim of this integrative review was to identify, describe, and synthesize previous primary studies on moral distress experienced by non-Western nurses. Review method: (...) Whittemore and Knafl’s integrative review methodology was used to structure and conduct the review of the literature. Research context and data sources: Key relevant health databases included the Ovid MEDLINE, CINAHL, Web of Science, and Google Scholar databases. Two relevant journals, Nursing Ethics and Bioethics, were manually searched. Ethical consideration: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources. Findings: A total of 17 primary studies published between 1999 and 2019 were appraised. There was an inconsistency with regard to moral distress levels and its relationship with demographic variables. The most commonly cited clinical causes of moral distress were providing futile care for end-of-life patients. Unit/team constraints (poor collaboration and communication, working with incompetent colleagues, witnessing practice errors, and professional hierarchy) and organizational constraints (limited resources, excessive administrative work, conflict within hospital policy, and perceived lack of support by administrators) were identified as moral distress’s stimulators. Negative impacts on nurses’ physical, psychological, and spiritual well-being were also reported. Conclusion: Further research is needed to investigate moral distress among other healthcare professions which may further build understanding. More importantly, interventions to address moral distress need to be developed and tested. (shrink)

BackgroundHow do the police officers perceive health risk, psychological distress, and work stress during the COVID-19 outbreak in China? This study explores the health risk perception, work stress, and psychological distress of police officers who worked at the front line to implement lockdown measures.Materials and MethodsWe conducted a large-scale field survey with police officers sample in the northwestern part of China from February 29 to March 7, 2020. Independent-sample T-test and ANOVA were used to analyze whether there are (...) differences in health risk perception, work stress, and psychological distress between different groups. The regression analysis was employed to figure out the factors that influence police officers’ psychological distress.ResultsResults showed a gender difference in perceiving work stress among police officers. Also, police officers with chronic disease perceived higher health risks, more psychological distress, and higher work stress. Additionally, police officers above 45 years old significantly perceived higher health risks than young officers did. It also revealed that working hours contribute to police officers’ health risk perception, psychological distress, and work stress. Finally, our results highlight that age, working hours, chronic disease, health risk perception, and work stress significantly contribute to police officers’ psychological distress.ConclusionOur research verifies that there is a gender difference in perceiving work stress among police officers. Police officers with ongoing medical issues and above 45 years old suffer more during the COVID-19 outbreak in China. Our research suggests that the government should pay more attention to their physical health and mental health. The heavy workload containing the COVID-19 extends police officers’ working hours, causing higher health risks, work stress, and psychological distress. This study contributes to the psychological distress literature and provides a way forward to other countries struggling to contain the COVID-19. (shrink)

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals’ moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts (...) in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change. (shrink)

Background Although, moral distress presents a serious problem among critical care nurses in many countries, limited research has been conducted on it. A validated scale has been developed to evaluate moral distress and has enabled cross-cultural comparison for seeking its root causes. Research aims This study aimed to (1) clarify the current status of moral distress among nurses who worked in critical care areas in Japan, (2) compare the moral distress levels among nurses in Japan with previously reported results from (...) the United States (US), and (3) explore the factors associated with moral distress. Research design A nationwide cross-sectional study was conducted. Participants and research context We conducted a self-administered questionnaire survey using the Measure of Moral Distress–Healthcare Professionals (MMD-HP) among critical care nurses who were randomly selected from hospitals across Japan. The mean differences between the two countries were compared using a Student's t-test with summary statistics. The factors associated with higher levels of moral distress were examined using a multiple regression analysis. Ethical considerations The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214 and M2019-045). Results We obtained 955 valid responses from 94 facilities. In Japan, the items with the highest moral distress scores were those related to aggressive/inappropriate treatment. The total MMD-HP score was significantly higher in Japanese nurses compared to US nurses (122.8 ± 70.8 vs 112.3 ± 73.2). Some factors, such as leadership experience, were associated with higher moral distress. Discussion The top root causes of moral distress were similar to potentially inappropriate treatments in both countries. Conclusion This study revealed the factors associated with higher moral distress and its characteristics in each country. These results can be used for reducing moral distress in the future. (shrink)

Workplace spirituality deals with paradoxes. This concept has been taken on board since the late 1980s, but very few human resource managers have realised that workplace spirituality could make an essential contribution to a better understanding of workplace and corporate reality. Increasing numbers of academic papers are being published on this subject but mere remain many grey areas for researchers. The aim of this paper is to use Simone Weil’s philosophy as a reading grid to get an insight into workplace (...) spirituality as a new paradigm of management. Initial studies attempting to apply Weil’s philosophy to management highlight the necessity for all the actors within the organisation to define their job tasks and contents according to their own way of thinking. Our interpretation of Weil’s philosophy also sheds light on the impossibility of dissociating thinking and acting and reminds us that work is done to nourish both the body and the soul. By concentrating on the spirituality of work, we can establish new links between ethics and human resource management. (shrink)

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

Background Licensed nurses working in long-term care facilities experience ethical challenges if not resolved can lead to moral distress. There is a lack of an English-language validated tool to adequately measure moral distress in the long-term care setting. Aims To describe the modification and psychometric evaluation of the Moral Distress Questionnaire. Methods Instrument development and psychometric evaluation. Internal consistency using Cronbach’s α to establish reliability was conducted using SPSS version 27.0 while SPSS Amos version 27.0 was used to perform a (...) confirmatory factor analysis of the Moral Distress Questionnaire Participants A national sample of US-licensed nurses who provided direct resident care in long-term care settings were recruited via a targeted sampling method using Facebook from 7 December 2020 to 7 March 2021. Ethical Consideration The study was approved by the university’s human research protection program. Informed consent was provided to all participants. Results A total of 215 participants completed the surveys. Confirmatory analysis indicated that the 21-item scale with a 4-factor structure for the Moral Distress Questionnaire model met the established criteria and demonstrates an acceptable model fit (CMIN/DF = 2.0, CFI = 0.82, TLI = 0.77, RMSEA = 0.07). Factor loadings for each item depict a moderate to a strong relationship (range 0.36–0.70) with the given underlying construct. Cronbach’s α coefficient was 0.87 for the overall scale and 0.60–0.74 for its subscales which demonstrate good reliabilities. Discussion This is the first English-language validated tool to adequately measure moral distress in the long-term care setting experienced by US long-term care nurses. This reliable and well-validated tool will help identify moral distress situations experienced by US long-term care nurses. Conclusion The modified 21-item English version of the Moral Distress Questionnaire is reliable tool that demonstrates good psychometric properties to validly measure sources of moral distress among direct resident care nurses. (shrink)

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

Moral distress (MD), the suffering experienced by professionals due to their restricted moral agency, has become a popular subject of study in the fields of social work and health care. Many of the existing measures of MD are targeted at certain professionals, such as health care workers, and are thus restricted to such contexts. This has challenged the conceptual development and empirical examination of MD as a phenomenon occurring across diverse professional groups in different work settings. This study (...) introduces a general measure of MD, the Moral Distress Instrument (MDI). It is not bound to specific professional contexts, and it aims to enable comparative and cross-disciplinary analyses of MD. The MDI consists of seven items that capture different forms of constrained moral agency and follow-up items measuring the level of distress related to these experiences. The reliability and validity of the MDI is investigated, and its distinctiveness from and associations with burnout are studied among a sample of Finnish social workers (n = 367). The MDI was shown to be a reliable and valid measure among the sample. The measures of MD and burnout were shown to tap separate constructs, although these experiences were strongly associated with each other. (shrink)

The aim of this study was to explore the existence of moral distress among nurses in Lilongwe District of Malawi. Qualitative research was conducted in selected health institutions of Lilongwe District in Malawi to assess knowledge and causes of moral distress among nurses and coping mechanisms and sources of support that are used by morally distressed nurses. Data were collected from a purposive sample of 20 nurses through in-depth interviews using a semi-structured interview guide. Thematic analysis of qualitative data (...) was used. The results show that nurses, irrespective of age, work experience and tribe, experienced moral distress related to patient/nursing care. The major distressing factors were inadequate resources and lack of respect from patients, guardians, peers and bosses. Nurses desire teamwork and ethics committees in their health institutions as a means of controlling and preventing moral distress. There is a need for creation of awareness for nurses to recognize and manage moral distress, thus optimizing their ability to provide quality and uncompromised nursing care. (shrink)

Background: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review Methods: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods (...) studies. Results: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended. (shrink)

Background: In the context of new reimbursement systems like diagnosis-related groups, moral distress is becoming a growing problem for healthcare providers. Moral distress can trigger emotional and physical reactions in nurses and can cause them to withdraw emotionally from patients or can cause them to change their work place. Objective: The aim of this pilot study was to develop an instrument to measure moral distress among acute care nurses in the German-speaking context, to test its applicability, and to obtain (...) initial indications of the instrument’s validity. Method: The study was designed in 2011 as a cross-sectional pilot survey. Conducted on eight units of one university hospital in German-speaking Switzerland, 294 registered nurses were asked to fill out a web-based questionnaire on moral distress. Ethical considerations: The study proposal was approved by the cantonal ethics committee. All participating nurses provided informed consent and were assured of data confidentiality. Results: The survey had a response rate of 55%. The results show the prevalence of statements on the questionnaire indicating situations with the potential to trigger moral distress. The entire range of answers was used in the responses. Most participants found the questionnaire comprehensible, while some criticized the phraseology of certain statements. Many more found the registration process prior to online access to be too time consuming. Nurses confirmed that the results reflect their subjective assessment of their situation and their experience of moral distress. Conclusion: The newly developed moral distress questionnaire appears to produce face validity and is sufficiently applicable for use in our study. The results indicate that moral distress appears to be a relevant phenomenon also in Swiss hospitals and that nurses were experiencing it prior to the introduction of Swiss diagnosis-related groups. (shrink)

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

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

Background and aim Ethical sensitivity of nurses often plays an important role in their occupational commitment and moral decision-making. In some working conditions, nurses are affected by ethical distress and fail to pursue correct ethical actions despite having knowledge and a tendency for moral practice. Therefore, the present study aimed to investigate the correlation between sensitivity and ethical distress in the nurses of patients with spinal cord injuries. Materials and methods This descriptive-analytical study was performed on 160 of the nurses (...) of patients with spinal cord injuries. The participants were selected through the purposive sampling method out of the nurses in Khatamolanbia and Sasan hospitals, Tehran, Iran. Data collection tools included the Moral Sensitivity Questionnaire by Han and Corley’s Moral Distress Scale. Data were analyzed by the independent t-test and Pearson correlation coefficient using the SPSS software version 19. Results The mean values of ethical sensitivity was 80.48 ± 14.45 and ethical distress among the subjects was 62.39 ± 3.54. Moreover, a significant negative correlation was observed between moral sensitivityand moral distress (P<0.05, r = −0.37). Conclusion According to the results of this study, increased ethical sensitivity is associated with diminished moral distress among the nurses of patients with spinal cord injuries. On the other hand, moral sensitivity is of considerable importance in nurses, especially in taking care of patients with special conditions. Consequently, it is recommended to provide some conditions for maintaining and enhancing ethical sensitivity in nurses taking care of patients with spinal cord injuries. (shrink)

Transplant coordinators play a pivotal role in the process of obtaining consent for live or dead donation of organs. The objective of the project is to unveil emotional experiences and ethical conduct of transplant coordinators using a qualitative research methodology. Ten transplant coordinators who have worked for more than 20 years in this job were recruited by using a purposive sampling technique. The transplant coordinators spoke of negative feelings and moral distress with regard to futile care of family members of (...) deceased donors as well as of living donors. Transplant coordinators experience moral distress on a daily basis; being compelled to compromise their integrity causes moral distress and moral residue, hence, training and support should be offered to them. (shrink)

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. (shrink)

Background Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time. Aim The aim of this study was to translate the MDT and adapt it to the Swedish cultural context. Research design The first part of this study concerns the translation of MDT to the (...) Swedish context, and the second part the psychometric testing of the Swedish version. Participants and research context 89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch’s ANOVA, Games–Howell post-hoc test and Pearson’s correlation analysis were done. Ethical considerations The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration. Results The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress. Conclusion The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context. (shrink)

The coronavirus disease imposes an unusual risk to the physical and mental health of healthcare workers and thereby to the functioning of healthcare systems during the crisis. This study investigates the clinical knowledge of healthcare workers about COVID-19, their ways of acquiring information, their emotional distress and risk perception, their adherence to preventive guidelines, their changed work situation due to the pandemic, and their perception of how the healthcare system has coped with the pandemic. It is based on a (...) quantitative cross-sectional survey of 185 Swiss healthcare workers directly attending to patients during the pandemic, with 22% of them being assigned to COVID-19-infected patients. The participants answered between 16th June and 15th July 2020, shortly after the first wave of COVID-19 had been overcome and the national government had relaxed its preventive regulations to a great extent. The questionnaire incorporated parts of the “Standard questionnaire on risk perception of an infectious disease outbreak”, which were adapted to the case of COVID-19. Clinical knowledge was lowest regarding the effectiveness of standard hygiene. Knowledge of infectiousness, incubation time, and life-threatening disease progression was higher, however still significantly lower than regarding asymptomatic cases and transmission without physical contact. 70% of the healthcare workers reported considerable emotional distress on at least one of the measured dimensions. They worried significantly more strongly about patients, elderly people, and family members, than about their own health. Adherence to preventive guidelines by the government displayed patterns such that not all guidelines were followed equally. Most of the participants were faced with a lack of protective materials, personnel, structures, processes, and contingency plans. An increase in stress level was the most prevalent among the diverse effects the pandemic had on their work situation. Better medical equipment, better protection for their own mental and physical health, more personnel, more comprehensive information about the symptoms of the disease, and a system of earlier warning were the primary lessons to be learned in view of upcoming waves of the pandemic. (shrink)

Moral distress in healthcare has been an increasingly prevalent topic of discussion. Most authors characterize it as a negative phenomenon, while few have considered its potentially positive value. In this essay, I argue that moral distress can reveal and affirm some of our most important concerns as moral agents. Indeed, the experience of it under some circumstances appears to be partly constitutive of an honorable character and can allow for crucial moral maturation. The potentially positive value, then, is twofold; moral (...) distress carries both aretaic and instrumental value. Granted, this position is not without its caveats, but by making these clear, I provide a novel framework for policy recommendations regarding when, if ever, we should work to reduce moral distress. (shrink)

Background As Korean neonatal nurses frequently experience the deaths of infants, moral distress occurs when they provide end-of-life care to the infants and their families. Although they need to care for the patients’ deaths and consequently experience burnout and turnover due to moral distress from the situation, there is a lack of a support for nurses. Moreover, not much information is available on the moral distress of neonatal nurses. There is a need to better understand Korean neonatal nurses’ moral distress (...) to develop and implement appropriate supports. Objective This study aimed to describe nurses’ experience of moral distress when they provide end-of-life care to infants and their families in neonatal intensive care units. Research design This is a secondary analysis qualitative study. Content analysis was performed based on Corley’s theory of moral distress to develop a codebook and identify themes regarding moral distress among the nurses. Participants and research context Qualitative data were collected from 20 nurses working in two NICUs in Seoul, South Korea. Ethical considerations The original study obtained permission from a university’s institutional review board (IRB). This secondary analysis study obtained the exemption from another university’s IRB. Nurses’ participation was voluntary and confidential. Findings The nurses’ moral distress was derived when they faced moral constraints and/or moral conflicts. Two distinct categories of moral constraints and four distinct categories of moral conflicts were identified among the neonatal nurses. In addition, impacts of moral distress on patients and nurses were identified. Conclusions This study identified occasions neonatal nurses experience moral distress, and thus can guide in developing and implementing effective interventions to decrease their moral distress and improve their resilience in end-of-life care by providing insight into neonatal nurses’ needs for support in end-of-life care. (shrink)