Background Midwives and nurses appear vulnerable to moral distress when caring for women whose babies are removed at birth. They may experience professional dissatisfaction and their relationships with women, families and colleagues may be compromised. The impact of moral distress may manifest as anger, guilt, frustration, anxiety and a desire to give up their profession. While there has been much attention exploring the concept of moral distress in midwifery, this is the first study to explore its association (...) in this context. Aim This article explores midwives’ experiences of moral distress when providing care to women whose babies were removed at birth and gives valuable insight into an issue nurses and midwives encounter in their profession. Methods Four mothers and eight midwives took part in this research. Narrative inquiry incorporating photo-elicitation techniques was used to generate data; mothers were interviewed face to face and midwives through focus groups. The images and audio data were collected, transcribed and analysed for emerging themes. For the purpose of this article, only the midwives’ stories are reported. This research received a favourable ethical opinion from the University of Surrey Ethics committee. Ethical considerations This study received a favourable ethical approval from a higher education institutes ethics committee. Results Midwives who care for women whose babies are removed at birth report it as one of the most distressing areas of contemporary clinical practice. Furthermore, they report feelings of guilt, helplessness and betrayal of the midwife–mother relationship. Many of the midwives in this study state that these experiences stay with them for a long time, far more than more joyful aspects of their role. Conclusion Midwives experience moral distress. Support systems, education and training must be available to them if we are to reduce the long-term impact upon them, alleviate their distress and prevent them from leaving the profession. (shrink)

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by (...) hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact. (shrink)

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 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. (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)

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)

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 (...) class='Hi'>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)

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: 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)

Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview (...) resides in the implications moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention. (shrink)

Background: Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress. Objectives: To explore healthcare professionals’ experiences of situations that generate moral distress in Swedish paediatric oncology. Research design: In this national study, data collection was conducted using the Swedish Moral Distress Scale-Revised. The data analysis included descriptive statistics and non-parametric analysis of differences between groups. Participants and research context: Healthcare professionals at all paediatric oncology (...) centres in Sweden were invited to participate. A total of 278 healthcare professionals participated. The response rate was 89%. Ethical considerations: In its advisory statement, the Regional Ethical Review Board decided that the study was of such a nature that the legislation concerning ethical reviews was not applicable. All participants received written information about the aim of the study and confidentiality. Participants demonstrated their consent by returning the survey. Findings: The two situations with the highest moral distress scores concerned lack of competence and continuity of personnel. All professional groups reported high levels of disturbance. Nurses rated significantly higher frequencies and higher total Moral Distress Scale scores compared to medical doctors and nursing assistants. Discussion: Lack of competence and continuity, as the two most morally distressing situations, confirms the findings of studies from other countries, where inadequate staffing was reported as being among the top five morally distressing situations. The levels of total Moral Distress Scale scores were more similar to those reported in intensive care units than in other paediatric care settings. Conclusion: The two most morally distressing situations, lack of competence and continuity, are both organisational in nature. Thus, clinical ethics support services need to be combined with organisational improvements in order to reduce moral distress, thereby maintaining job satisfaction, preventing a high turnover of staff and ensuring the quality of care. (shrink)

Background: Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic. Objective: To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency. Research design: A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively (...) sampled 31 nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020. Ethical considerations: We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore. Results: We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies. Discussion/Conclusion: Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses’ moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences. (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: 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 and workplace bullying are important issues in the nursing workplace that appear to affect nurse’s burnout. Aim: To investigate the relationship between moral distress and burnout in Iranian nurses, as mediated by their perceptions of workplace bullying. Ethical considerations: The research was approved by the committee of ethics in research of the Urmia University of Medical Sciences. Method: This is a correlation study using a cross-sectional design with anonymous questionnaires as study instruments (i.e. Moral (...) class='Hi'>Distress Scale-Revised, Maslach Burnout Inventory and The Negative Acts Questionnaire-Revised). Data were collected from 278 nurses from five teaching hospitals in Urmia, the capital of Western Azerbaijan, northwest of Iran. Structural equation modeling and bootstrapping procedures were employed to recognize the mediating role of their perceptions of workplace bullying. Results: The mean score of moral distress, burnout, and the Negative Acts Questionnaire-Revised Scale among the participants were 91.02 ± 35.26, 79.9 ± 18.27, and 45.4 ± 15.39, respectively. The results confirmed our hypothesized model. All the latent variables of study were significantly correlated in the predicted directions. The moral distress and bullying were significant predictors of burnout. Perception of bullying partially mediated the relationship between moral distress and burnout. The mediating role of the bullying suggests that moral distress increases burnout, directly and indirectly. Conclusion: Nursing administrators should be conscious of the role of moral distress and bullying in the nursing workplace in increasing burnout. (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)

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)

Nurses and other medical practitioners often experience moral distress: they feel an anguished sense of responsibility for what they take to be their own moral failures, even when those failures were unavoidable. However, in such cases other people do not tend to think it is right to hold them responsible. This is an interesting mismatch of reactions. It might seem that the mismatch should be remedied by assuring the practitioner that they are not responsible, but I argue that this (...) denies something important that the phenomenon of moral distress tells us. In fact, both the practitioners’ tendencies to hold themselves responsible and other people’s reluctance to hold the practitioners responsible get something right. The practitioners may be right that they are responsible in the sense of having failed to meet a binding moral requirement, even when the requirement was impossible to meet. This makes moral distress a fitting response because it correctly represents their own action as a wrongdoing. However, others may meanwhile be right that the practitioners are not responsible in the sense of being culpable and blameworthy. To blame others, or oneself, for certain failures, including those that are unavoidable, would be unfair. My claim depends on distinguishing between the fittingness and the fairness of holding someone (including oneself) responsible for moral failure. Having drawn the distinction, I suggest that moral distress should be addressed in a way that both recognizes it as a fitting response and avoids the unfairness of blame. (shrink)

Background Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience. Aim The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil. Research design The research design is the qualitative study with discursive textual analysis. (...) Participants and research context : 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions. Ethical considerations The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity. Findings Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation. Conclusion From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience. (shrink)

Nurses are frequently confronted with ethical dilemmas in their nursing practice. As a consequence, nurses report experiencing moral distress. The aim of this review was to synthesize the available quantitative evidence in the literature on moral distress experienced by nurses. We appraised 19 articles published between January 1984 and December 2011. This review revealed that many nurses experience moral distress associated with difficult care situations and feel burnout, which can have an impact on their professional position. Further (...) research is required to examine worksite strategies to support nurses in these situations and to develop coping strategies for dealing with moral distress. (shrink)

Moral distress has been characterised in the nursing literature as a major problem affecting nurses in all healthcare systems. It has been portrayed as threatening the integrity of nurses and ultimately the quality of patient care. However, nursing discourse on moral distress is not without controversy. The notion itself is conceptually flawed and suffers from both theoretical and practical difficulties. Nursing research investigating moral distress is also problematic on account of being methodologically weak and disparate. Moreover, the (...) ultimate purpose and significance of the research is unclear. In light of these considerations, it is contended that the notion of moral distress ought to be abandoned and that concerted attention be given to advancing inquiries that are more conducive to improving the quality and safety of moral decision-making, moral conduct and moral outcomes in nursing and healthcare domains. (shrink)

Background: Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students. Aim: To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing. Research design: A descriptive qualitative design was employed to explore the community health nursing experiences of (...) the nursing students that led them to have moral distress. Participants and research context: The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year. Ethical considerations: Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. Findings: Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community. Conclusion: This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the “real world,” where the ideals they have will be constantly challenged and tested. (shrink)

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and (...) APA PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions. (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)

Their nursing experience and/or training may lead students preparing for the nursing profession to have less moral distress and more favorable attitudes towards a hastened death compared with those preparing for other fields of study. To ascertain if this was true, 66 undergraduates (54 women, 9 men, 3 not stated) in southeastern USA completed measures of moral distress and attitudes towards hastening death. Unexpectedly, the results from nursing and non-nursing majors were not significantly different. All the present students (...) reported moderate moral distress and strong resistance to any efforts to hasten death but these factors were not significantly correlated. However, in the small sample of nurses in training, the results suggest that hastened death situations may not be a prime reason for moral distress. (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 Over the past few decades, moral distress has been examined in the nursing literature. It is thought to occur when an individual has made a moral decision but is unable to act on it, often attributable to constraints, internal or external. Varying definitions can be found throughout the healthcare literature. This lack of cohesion has led to complications for study of the phenomenon, along with its effects to nursing practice, education and targeted policy development. Objectives The aim of (...) this analysis was to uncover unique definitions of moral distress as found in the nursing literature and to examine the relationship between these definitions. Research Design and Context Morse’s method of concept clarification was applied given the large body of literature which includes definitions, descriptions and measurements of the concept in research. The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing, and contrasting attributes, antecedents and consequences of each category. Findings Each of the 18 included studies described constraints in their definition of moral distress, whether implied or explicitly stated. External constraints are widely described as obstacles outside of the individual, whether institutional, systemic or situational, while internal constraints are located within the individuals themselves and are described as personal limitations, failings or weakness of will. Conclusion Upon reviewing these definitions, we determined that the term ‘internal constraints’ is problematic due to the emphasis of responsibility on the individual experiencing moral distress. We propose an alteration to ‘internal characteristics’ that will assume less responsibility of change from the individual to place a heavier onus on systemic and institutional constraints. (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)

Moral distress is defined as the inability to act according to one’s own core values. During the COVID-19 pandemic, moral distress in medical personnel has gained attention, related to the impact of pandemic-associated factors, such as the uncertainty of treatment options for the virus and the accelerated pace of deaths. Measures to provide aid and mitigate the long-term pandemic effect on providers are starting to be designed. Yet, little has been said about the moral distress experienced by (...) patients and the relational and additive effect on provider moral distress. Pandemic-associated factors affecting moral distress in patients include the constraining effects of isolation on spiritual and religious traditions as well as the intentional separation of patients from their families. This paper will explore the idea that patients are suffering their own moral distress and further how this impacts the intensity of moral distress experienced by the providers—nurses and physicians. The paucity of research in this area with the implications on patient’s distress, decision making, and distress experienced by providers compels further investigation and analysis. (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)

Objective:The purpose of this study was to describe the current situation of moral distress and to explore its influencing factors among Chinese nurses.Methods:This is an exploratory, descriptive design study. A total of 465 clinical nurses from different departments in three Grade-III, Level-A hospitals in Jinan, Shandong Province, completed the questionnaires, including demographics questionnaire, Chinese version of Moral Distress Scale–Revised, and Job Diagnostic Survey.Ethical considerations:The study was approved by the university ethics board and the local health service director.Results:The total (...) score of Moral Distress Scale–Revised was 36.01 ± 24.02 points. The mean frequency and intensity scores of moral distress were 1.13 ± 0.49 and 1.09 ± 0.58, respectively. The level of moral distress among Chinese clinical nurses was low, and the frequency and intensity of moral distress were on low to moderate level. The level of moral distress experienced by clinical nurses is associated with demographics features and job characteristics, including age, education degree, department, task significance, autonomy, and dealing with others.Conclusion:Our conclusion suggests that hospital and organizational administrations should attach much importance to the moral distress experienced by clinical nurses in China. Further studies should focus on interventions about how to reduce the levels of the frequency and intensity of moral distress among clinical nurses. (shrink)

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

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

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: Nurses and nursing students appear vulnerable to moral distress when faced with ethical dilemmas or decision-making in clinical practice. As a result, they may experience professional dissatisfaction and their relationships with patients, families, and colleagues may be compromised. The impact of moral distress may manifest as anger, feelings of guilt and frustration, a desire to give up the profession, loss of self-esteem, depression, and anxiety. Objectives: The purpose of this review was to describe how dilemmas and environmental, (...) relational, and organizational factors contribute to moral distress in undergraduate student nurses during their clinical experience and professional education. Research design: The research design was a systematic literature review. Method: The search produced a total of 157 articles published between 2004 and 2014. These were screened with the assessment sheet designed by Hawker and colleagues. Four articles matched the search criteria (one quantitative study and three qualitative), and these were separately read and analyzed by the researchers. The process of review and analysis of the data was supervised by a colleague experienced in moral distress who provided an independent quality check. Ethical consideration: Since this was a systematic review, no ethical approval was required. Findings: From the analysis, it emerged that inequalities and healthcare disparities, the relationship with the mentor, and students’ individual characteristics can all impact negatively on the decisions taken and the nursing care provided, generating moral distress. All these factors condition both the clinical experience and learning process, in addition to the professional development and the possible care choices of future nurses. Conclusion: Few studies dealt with moral distress in the setting of nurse education, and there is a knowledge gap related to this phenomenon. The results of this review underline the need for further research regarding interventions that can minimize moral distress in undergraduate nursing students. (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)

Background In the US, many patients forgo recommended care due to cost. The ANA Code of Ethics requires nurses to give care based on need. Therefore, US nurses are compelled to practice in a context which breaches their professional ethical code. Research Objectives This study sought to determine if nurses do care for patients who forgo treatment due to cost (PFTDC) and if so, does this result in an experience of moral distress (MD). Research Design Semi-structured interviews were transcribed (...) and analyzed using a qualitative content analysis. Participants and Research Context A convenience sample of 20 nurses in practice for at least one year from a variety of health care setting participated. Ethical Considerations This project was approved by the Michigan State University Biomedical Institutional Review Board. Results There were 19 female and one male nurse-participants, averaging 47 years old with an average of 10 years in practice. 18 reported caring for PFTDC. These 17 nurse-participants experienced a moderate degree of MD as a result, averaging 5.4 of 10 on the Moral Distress Thermometer. In the interviews, the following themes were identified, strategies to help PFTDC, and the broken US health care system which had the subthemes of preference for business over patient-oriented benefit, PFTDC using the emergency department, and limited support for treatment/management of PFTDC. Conclusions The existence of this phenomenon places the profession of nursing in the US in a position of moral compromise and threatens to corrupt the institution of nursing in the US. (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)

Background The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity. Objectives To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral (...) class='Hi'>distress and career identity among nurses. Design A quantitative, cross-sectional study. Methods A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses’ Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement. Ethical consideration Research ethics approval was obtained from the researcher’s university and hospital where this study was conducted prior to data collection. Findings Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity ( β = −0.230 to −0.163, p < 0.01). Discussion The findings reveal a relationship between moral distress, moral courage, and career identity among nurses. Conclusion By paying attention to nurses’ moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses. (shrink)

Neoliberalism has ushered in a rise in managerialism, technocracy and bureaucratisation in residential child care where economy, efficiency, and effectiveness have been prioritised over the moral imperative to care. One implication has been the commodification of children who are traded in a culture of procurement and commissioning compounded by a climate of austerity, and where moral regulation has been replaced by contractual regulation. The impact of this upon the care that children receive has raised concern. The impact upon frontline carers (...) of intractable moral challenges which this climate presents in their role of caring each day is less well understood. The naming of an experience can provide an important starting place to understanding and challenging it. This article draws upon the phenomenon of ‘moral distress’, which is well documented in the medical field, and considers the transferability of this phenomenon from nursing to residential child care. It proposes that moral distress discourse may provide a language to residential child care workers through which their experience of the betrayal of the moral fabric of their work may be articulated. (shrink)

Bodily pain and distress come in many forms. They can well up from within at times of serious illness, but the body can also be subjected to harsh treatment from outside. The medical system is often cold and depersonalized, and much worse are conditions experienced by prisoners in our age of mass incarceration, and by animals trapped in our factory farms. In this pioneering book, Drew Leder offers bold new ways to rethink how we create and treat distress, (...) clearing the way for more humane social practices. Leder draws on literary examples, clinical and philosophical sources, his medical training, and his own struggle with chronic pain. He levies a challenge to the capitalist and Cartesian models that rule modern medicine. Similarly, he looks at the root paradigms of our penitentiary and factory farm systems and the way these produce distressed bodies, asking how such institutions can be reformed. Writing with coauthors ranging from a prominent cardiologist to long-term inmates, he explores alternative environments that can better humanize—even spiritualize—the way we treat one another, offering a very different vision of medical, criminal justice, and food systems. Ultimately Leder proposes not just new answers to important bioethical questions but new ways of questioning accepted concepts and practices. (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)

IntroductionWhen professional nurses face an obstacle in their perfect purposes, they would experience moral distress which is a suffering situation. This study aims at exploring conditions which l...

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

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)

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 Moral distress is a complex and challenging issue in the nursing profession that can negatively affect the nurses’ job satisfaction and retention and the quality of patient care. This study focused on describing the resources and constraints, consequences, and interventions of moral distress in nurses. Methods In a literature review, an extensive electronic search was conducted in databases including PubMed, ISI, Scopus as well as Google Scholar search engine using the keywords including “moral distress” and “nurses” (...) to identify resources, constraints, consequences, and interventions about moral distress in nurses, from the earliest records up to 26 December 2020. The required data were extracted from 61 relevant studies by two independent reviewers. Results Resources and constraints in the occurrence of moral distress among nurses can be divided into three general categories including internal factors, clinical factors, and external factors. The consequences of moral distress on nurses and the medical system reduced moral sensitivity, development of psychological and physical health problems, and the intention to leave the profession. The potential effective interventions were the implementation of integrated communication programs, strengthening physician–nurse collaboration, nursing involvement in clinical decision-making and end-of-life issues, social support, using a resiliency bundle, interdisciplinary discussion, and promoting nurses’ ethical and communication skills. Conclusion There are a wide range of resources and constraints impacting moral distress in nurses that could lead to negative consequences. Further studies are necessary to identify, evaluate, and implement a range of potential effective interventions for the management of moral distress in nurses. (shrink)

Background: Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention. Research purpose: The purpose of this article was to investigate the nature of clinician distress. Research design: Qualitative inductive dimensional analysis. Participants and research context: After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis. Ethical considerations: This study did not (...) require ethical review and the authors adhered to appropriate academic standards in their analysis. Findings: A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians’ perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one’s values due to a precipitating event. Discussion: This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician’s own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed. Conclusion: For clinicians, learning to recognize one’s perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness. (shrink)

Ong, Caroline As health systems become more complex, moral distress is increasingly being recognised as a significant phenomenon amongst health professionals. It can be described as the state of being distressed when one is unable to act according to what one believes to be morally right. It may compromise patient care, the health professional involved and the organisation. Cumulative experiences of incompletely resolved moral distress - a phenomenon which is called moral residue - may leave us susceptible to (...) more frequent and more severe moral distress. Clear open communication, respect, inclusivity, openness to differences, compassion, support, education and the capacity to grow in self-awareness are key aspects in minimising moral distress. Early recognition of its symptoms and addressing both personal and external constraints of actions can also minimise moral residue and build resilience to further distress. (shrink)

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” (...) encompasses not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim. (shrink)