Higher Levels Of Moral Distress Research Articles

Let's Talk About Ethics: Addressing Ethical Tensions and Building Moral Resilience in the Occupational Therapy Profession.

Health professionals across all care delivery settings, including occupational therapy practitioners, are experiencing high levels of moral distress. The mental, emotional, and physical consequences of unresolved moral distress are resulting in burnout, decreased quality of care, and poor patient outcomes. Moral resilience is a teachable and learnable skill that can nullify some of the adverse consequences of moral distress. To ensure quality care outcomes and improve the well-being of individual occupational therapy practitioners and the profession, it is essential that occupational therapy practitioners be provided with the education, training, resources, and strategies needed to address moral distress, foster moral resilience, and cultivate the skills necessary to cope with ethical tensions. In this column, we call the profession to action to address the phenomenon of moral distress as it relates to occupational therapy practitioner well-being. We also discuss resources and strategies for addressing ethical tensions and building moral resilience in occupational therapy practice.

Strategies to mitigate moral distress as reported by eldercare professionals

ABSTRACT Eldercare workers experience higher levels of moral distress than other health and social care service workers. Moral distress is a psychological response to a morally challenging event. Very little is known about moral distress in the context of eldercare and about the mechanisms of preventing or mitigating moral distress. This qualitative study was conducted as part of the “Ensuring the availability of staff and the attractiveness of the sector in eldercareservices” project in Finland in 2021. The data were from 39 semi-structured interviews. This qualitative interview data were examined using two-stage content analysis. The key finding of this study, as reported by eldercare professionals, is that strategies to mitigate moral distress can be found at all organizational levels : organizational, workplace and individual. The tools that emerged from the interviews fell into four main categories: 1) organizational support and education 2) peer support 3) improving self-care and competence and 4) defending patients. The main identified categories confirmed the earlier findings but the qualitative, rich research interview data provided new insights into a little-studied topic: mitigating moral distress in eldercare. The main conclusion is that, in order to mitigate moral distress, ethical competence needs to be strengthened at all organizational levels.

Intent to stay, moral distress, and nurse practice environment among long-term care nurses: A cross-sectional questionnaire survey study.

Many long-term care facilities in the United States face significant problems with nurse retention and turnover. These challenges are attributed, at least in part, to moral distress and a negative nurse practice environment. The purpose of the study was divided into two parts: first, to investigate the relationships among nurse practice environment, moral distress, and intent to stay; second, to explore the potential mediating effect of the nurse practice environment on the intent to stay among those with high levels of moral distress. This study was a descriptive, cross-sectional survey using targeted sampling. A total of 215 participants completed the surveys. Participants were nationally representative of long-term care nurses by age, years of experience, employment status, and type of health setting. This study was an online national survey of long-term care nurses' perceptions of their intent to stay, moral distress level (Moral Distress Questionnaire), and nurse practice environment (Direct Care Staff Survey). Structural equation modeling analysis explored intent to stay, moral distress, and the nurse practice environment among long-term care nurses. The mean moral distress score was low, while the mean nurse practice environment and intent to stay scores were high. Moral distress had a significant, moderately negative association with the nurse practice environment (β = -0.41), while the nurse practice environment had a significant, moderately positive association with intent to stay (β = 0.46). The moral distress had a significant, moderately negative association with intent to stay (β = -0.20). The computed structural equation modeling suggested a partially mediated model (indirect effect = -0.19, p = 0.001). Since the nurse practice environment partially mediates the relationship between moral distress and intent to stay, interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession. Our study demonstrated that the nurse practice environment mediates moral distress and intent to stay. Interventions to improve the nurse practice environment are crucial to alleviating moral distress and enhancing nurses' intent to stay in their jobs, organizations, and the nursing profession.

Impact of Case Review Debriefings on Moral Distress of Extracorporeal Membrane Oxygenation Nurses.

Moral distress occurs when nurses know the ethically correct action to take but are restrained from taking it. Moral distress is prevalent in nurses who work in intense stress situations, as do extracorporeal membrane oxygenation nurses. Nurses who work in critical care settings have higher levels of moral distress than nurses who work in other practice areas. The purpose of this project was to evaluate the effectiveness of case review debriefings on moral distress of extracorporeal membrane oxygenation nurses. Thirty-nine critical care registered nurses with specialty training in extracorporeal membrane oxygenation were invited to participate in this clinical improvement project. The intervention consisted of 2 case review debriefings. The Moral Distress Scale-Revised and the Moral Distress Thermometer were used to measure long-term and acute (short-term) moral distress. Of a potential range of 0 to 336, the mean Moral Distress Scale-Revised score was 134.0 before intervention and 131.8 after intervention. The frequency of experiencing moral distress did not change after intervention, but the level of moral distress increased after intervention. Moral Distress Thermometer scores decreased for 80% of participants and increased for 20%. Five items related to perceptions of prolonging death and suffering were the most frequent causes of moral distress. Developing strategies and providing opportunities to mitigate moral distress are crucial to a healthy future nursing workforce. Implications include the potential for improved patient care, decreased turnover rates and costs, and improved nurse satisfaction rates.

307 Reducing Moral Distress in Burn/trauma Intensive Care Unit Nurses

Abstract Introduction There is minimal research regarding moral distress in Burn/Trauma intensive care unit (ICU) nurses compared to other nursing specialties. However, there is evidence that indicates there are high levels of moral distress in this nursing population which increases the risk for psychological or physical distress, burnout, and high nursing turnover. Identifying and utilizing an effective intervention, such as nursing huddles with clinical ethicists, can help reduce the impact of moral distress in this nursing population. Methods An evidenced-based practice project using the IOWA Model was conducted over a six week period on a ten bed Burn/Trauma ICU. Convenience sampling was utilized to capture a total of 24 registered nurses (RN) in the initial survey period. Each of the nurses (n=24) completed the Moral Distress Thermometer (MDT) and the Measure of Moral Distress for Healthcare Providers (MMD-HP) prior to signing up for a nursing huddle with the clinical ethicists. There were five nursing huddles conducted with clinical ethicists on Microsoft Teams over the span of four weeks. Each nurse that participated was required to complete the pre-intervention surveys prior to participating in the nursing huddles and also complete the post MDT evaluation. The MDT pre and post-intervention scores were compared to evaluate the impact of nursing huddles with clinical ethicists on moral distress among RNs working in a Burn/Trauma ICU. Results Out of the 24 RNs, 62.5% (n=15) completed the pre-intervention surveys, nursing huddles, and post-intervention surveys. A comparison of the pre-intervention and post-intervention MDT scores showed approximately a 44% decrease in acute moral distress in the Burn/Trauma ICU nurses. In addition, the MMD-HP identified 10 consistent triggers of moral distress in all 24 RNs during the initial survey period. Some reoccurring themes included futile care, false hope, and unnecessary care with benefit to the patient. Conclusions Nursing huddles with clinical ethicists considerably reduced the impact of the moral distress identified in Burn/Trauma ICU nurses. These findings support the need for continuous evaluation of moral distress and implementation of interventions to reduce moral distress in this nursing specialty. Applicability of Research to Practice Identifying and mitigating moral distress in the Burn/Trauma ICU nurse population is absolutely necessary. The unique ethical dilemmas that arise on a daily basis requires continuous monitoring and implementation of varying interventions to support the nurses and reduce the level of moral distress they may be experiencing. Moral distress does not dissipate on its own. Moral distress needs to be addressed and recognized as a serious and prevalent issue in this nursing population.

Spanish psychometric properties of the moral distress scale—revised: a study in healthcare professionals treating COVID-19 patients

BackgroundMoral distress appears when a healthcare professional is not able to carry out actions in accordance with their professional ethical standards. The Moral Distress Scale-Revised is the most widely used to assess levels of moral distress, but it is not validated in Spanish. The aim of the study is to validate the Spanish version of the Moral Distress Scale – utilised within a sample of Spanish healthcare professionals treating COVID–19 patients.MethodsThe original (english) and the portuguese and french versions of the scale were translated into spanish by native or bilingual researchers and reviewed by an academic expert in ethics and moral philosophy as well as by a clinical expert. Research design: Descriptive cross-sectional study carried out using a self-reporting online survey. The data was collected between June- November 2020. A total of 661 professionals responded to the survey (N = 2873). Participants: healthcare professionals with more than two weeks of experience treating COVID–19 patients at the end of their life and working in the public sector of the Balearic Islands Health Service (Spain). Analyses included descriptive statistics, competitive confirmatory factor analysis, evidence on criterion-related validity and estimates of reliability. The study was approved by the Research Ethics Committee at the University of Balearic Islands.ResultsAn unidimensional model in which a general factor of moral distress explained by 11 items of the Spanish version of the MDS–R scale was an adequate representation of the data: χ2(44) = 113.492 (p 0.001); Comparative Fit Index = 0.965; Root Mean Square Error of Approximation = 0.079[0.062,0.097]; and Standarized Root Mean-Square = 0.037. Evidence of reliability was excellent: Cronbach’s alpha = 0.886 and McDonald’s omega = 0.910. Moral distress was related to discipline, with nurses having statistically significant higher levels than physicians. Additionally, moral distress successfully predicted professional quality of life, with higher levels of moral distress being related to poorer quality of life.ConclusionsThe Spanish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by health professionals. This tool will be highly useful for managers and applicable to a variety of healthcare professionals and settings.

Moral distress and ethical climate in pediatric oncology care impact healthcare professionals' intentions to leave.

To assess perceptions of ethical climate, experiences of moral distress, and intentions to leave among healthcare professionals in Nordic pediatric oncology care. A cross-sectional survey with registered nurses, physicians, and nursing assistants at 20 Nordic pediatric cancer centers. Data were collected by using translated versions of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Descriptive analyses and non-parametric tests were used to describe, summarize, and compare data. According to 543 healthcare professionals (response rate 58%), the ethical climate in Nordic pediatric oncology care was positive. Inadequate staffing levels, poor continuity and lack of time were the most common causes of moral distress. Registered nurses experienced significantly higher levels of moral distress compared to physicians and nursing assistants. About 6% of the respondents considered leaving due to moral distress. Typically, they assessed the ethical climate as less positive and reported higher levels of moral distress than those who had no intention to leave. Organizational actions that ensure safe staffing levels and improve the continuity of care are needed to prevent moral distress and high staff turnover.

Moral distress among neonatologists working in neonatal intensive care units in Greece: a qualitative study

BackgroundWorking as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration.MethodsThis prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach.ResultsA variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists’ moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists’ constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists’ moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant’s best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists’ colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists’ constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time.ConclusionsWe concluded that neonatologists’ moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

Understanding the Relationships Between Health Care Providers' Moral Distress and Patients' Quality of Death.

Introduction: Moral distress is a commonly recognized phenomenon among health care providers; however, the experience of moral distress by staff caring for patients who die during an acute care hospital stay has not been previously examined. It also remains unclear how the quality of a death may impact moral distress among these providers. Objectives: We sought to understand levels of moral distress experienced by intern physicians and nurses who provided care during a patient's final 48 hours of life, and how the perceived quality of death impacted moral distress. Materials and Methods: We utilized a mixed-method prospective cohort design, surveying nurses and interns following inpatient hospital deaths at an academic safety-net hospital in the United States. Participants completed surveys and answered open-ended questions to evaluate moral distress and the quality of the patient's death. Results: A total of 126 surveys were sent to nurses and interns caring for 35 patients who died, with 46 surveys completed. Overall moderate-to-high levels of moral distress were identified among participants, and we found that higher levels of moral distress correlated with lower perceived quality of death. We identified five themes in our qualitative analysis highlighting the challenges nurses and interns face in end-of-life care, including the following: poor communication, unexpected deaths, patient suffering, resource limitations, and failure to prioritize a patient's wishes or best interests. Conclusions: Nurses and interns experience moderate-to-high levels of moral distress when caring for dying patients. Lower quality of end-of-life care is associated with higher levels of moral distress.

Impressions of the Nursing Profession Among Nursing Students and New Graduates During the First Wave of COVID-19: A Qualitative Content Analysis.

The COVID-19 pandemic has been a defining event for the next generation of the nursing workforce. Complex pandemic practice environments have raised concerns for the preparation and support of novice nurses, even as a multitude of nurses leave the profession. Researchers sought to examine nursing students' and new graduate nurses' impressions of the nursing profession in contrasting regions of New York State during the first wave of the COVID-19 pandemic. Inductive content analysis was performed on narrative text responses (n = 295) drawn from a larger multisite mixed-methods survey. Five subconcepts were abstracted, leading to the main concept of shocked moral distress . Nursing students and new graduate nurses have experienced high levels of moral distress but remain committed to the profession. Building moral resilience, fostering ethical decision making, and implementing protective policies can reduce the incidence of moral distress.

Veterinarians and moral distress.

Assess veterinarians' reported levels of moral distress and professional well-being. Determine the predictive value of moral distress, controlling for demographic factors, on veterinarians' levels of Professional Fulfillment, Work Exhaustion, Disengagement, and Burnout. Members of the Veterinary Information Network. An electronic survey distributed via the Veterinary Information Network data collection portal. A total of 1,919 veterinarians completed the survey. For both associates and owners, gender and age were significant predictors of moral distress with younger female veterinarians reporting higher levels of distress than older male veterinarians. For associates, age was a positive predictor and moral distress score was a negative predictor of Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors for Work Exhaustion. For Interpersonal Disengagement and Burnout, age was a negative predictor and moral distress score was a positive predictor. For owners, age was a positive predictor and moral distress score was a negative predictor for Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion, Interpersonal Disengagement, and Burnout. We found that, controlling for age and gender, higher levels of moral distress predicted lower levels of Professional Fulfillment and higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. Given the prevalence of moral distress and its impact on mental health, it is imperative that the veterinary field provide training and education on how to recognize and navigate ethical conflicts.

Estimation of moral distress among nurses: A systematic review and meta-analysis.

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. To estimate moral distress among nurses. 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. The protocol of this project was registered in the PROSPERO database under decree code of CRD42021267773. 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. 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.

Health Inequities and Moral Distress Among Community Health Nurses During the COVID-19 Pandemic

     The core values of community health nursing practice are rooted in the social determinants of health, health equity and social justice.  Throughout the COVID-19 pandemic, community health nurses (CHNs) witnessed first-hand the impact on individuals in situations of marginalization. This research inquiry explored how health inequities among client populations contributed to experiences of MD among CHNs in Canada during the pandemic.      A total of 245 CHNs from across Canada participated in an online survey. Participants reported that during the pandemic individuals living in situations of marginalization were disproportionately impacted. CHNs were unable to provide the necessary health promotion interventions and experienced high levels of moral distress. The negative impact of the pandemic on individuals living in situations of marginalization illuminated the intersecting social and structural inequities that drive negative health outcomes and emphasized the need to adopt an equity focus for current and future pandemic planning, response, and recovery.    

Palliative and hospice social workers' moral distress during the COVID-19 pandemic.

Moral distress is associated with adverse outcomes contributing to health-care professionals' worsened mental and physical well-being. Medical social workers have been frontline care providers throughout the COVID-19 pandemic, and those specializing in palliative and hospice care have been particularly affected by the overwhelming numbers of those seriously ill and dying. The main objectives of this study were (1) to assess palliative and hospice social workers' experiences of moral distress during COVID-19 and (2) to identify and describe participants' most morally distressing scenarios. Using a mixed-methods approach, participants completed an online survey consisting of the Moral Distress Thermometer (MDT) and open-ended text responses. A total of 120 social work participants responded to the study, and the majority of participants (81.4%) had experienced moral distress with an average MDT score of 6.16. COVID-19 restrictions emerged as the main source of moral distress, and an overlap between the clinical and system levels was observed. Primary sources of moral distress were grounded in strict visitation policies and system-level standards that impacted best practices and personal obligations in navigating both work responsibilities and safety. In the first year of the COVID-19 pandemic, palliative and hospice social work participants indicated high levels of moral distress. Qualitative findings from this study promote awareness of the kinds of distressing situations palliative and hospice social workers may experience. This knowledge can have education, practice, and policy implications and supports the need for research to explore this aspect of professional social work.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review.

Background: No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley’s instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale–Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress. Methods: A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological s Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle–Ottawa Scale. Results: Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review’s findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores. Conclusions: This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Moral distress among critical care nurses: A cross-cultural comparison.

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. 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. A nationwide cross-sectional study was conducted. 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. The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214 and M2019-045). 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. The top root causes of moral distress were similar to potentially inappropriate treatments in both countries. 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.

A national study of moral distress among U.S. internal medicine physicians during the COVID-19 pandemic.

BackgroundThere have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress.MethodsWe conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales.ResultsThe response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care.ConclusionsThe intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

How hospital chaplains develop and use rituals to address medical staff distress

Physicians and nurses face high levels of moral distress and burnout, exacerbated by the COVID-19, yet are often busy, without time for extended interventions. Hospital chaplains have recently been asked to assist staff, but many questions arise concerning whether they do so, and if so, how and when, and whether they may vary in doing so. Thirty-one telephone interviews of ∼1 ​h each were conducted with 21 board-certified chaplains to examine these and related issues. Respondents reported how they help staff, often creating, on their own, innovative kinds of practices that appear to take the form of rituals. These rituals vary in audience (physicians, nurses and/or other staff, with or without patients or families), form (from open-ended to structured), formality (from formal to informal), timing (at hospital discharge, time of death or after death), duration (from a few minutes to longer), frequency (from once to several times or ongoing), content (expressing and/or reframing feelings and experiences), and activities (e.g., talking, eating and/or making commemorative objects). Such rituals can help staff cope with death, grief, and other stresses. Challenges arise, including hospital leaders’ wariness, resistance or lack of support, and staff time constraints, making briefer sessions more practical. These data highlight how chaplains can assist staff through use of rituals, and learn from innovations/initiatives devised by colleagues elsewhere. Chaplains can thus enhance what they do as individuals and as a profession. These data have critical implications for future research, education and practice for physicians, nurses, hospital administrators, chaplains and others.

The Relationship between Resilience and Moral Distress among Iranian Critical Care Nurses: A Cross-sectional Correlational Study.

Critical care nurses usually experience high levels of moral distress due to the nature of their work. Resilience in critical care nurses can potentially facilitate effective adaptation to physical and emotional burden of caring for critically ill patients. The present study aimed to evaluate the relationship between resilience and moral distress among Iranian critical care nurses. In this cross-sectional correlational study, 144 critical care nurses working in intensive care units (ICUs) of five teaching hospitals affiliated to Mazandaran University of Medical Sciences, were selected randomly, from July to October 2020. Data were collected using a 36-item moral distress questionnaire and a 25-item Connor-Davidson Resilience Scale (CD-RISC) questionnaire. Data were analyzed using independent t-test, ANOVA and Pearson correlation coefficient using SPSS 21 software. The mean score of moral distress in nurses was 66.93±2.47 and 95.8% of nurses had low-level moral distress. The mean score of resilience in nurses was 90.66±10.92 and 73.6% of nurses had high levels of resilience. There was a statistically significant relationship between the scores of moral distress and resilience. Also, there was a significant positive relationship between work experience and two subscales of resilience as "trust in individual instincts, tolerance of negative emotions" and "impact of spirituality" (p<0.001). The results of the present study indicated a positive correlation between resilience and moral distress in nurses working in ICUs. It seems that when moral distress increases, critical care nurses increasingly use the mechanism of resilience for better permanence and active presence in the organization.

Moral distress: Does this impact on intent to stay among adult critical care nurses?

Moral distress is recognized as an international problem that contributes to decreased work productivity, job dissatisfaction and intent to leave for adult Critical Care nurses. To explore Critical Care nurses moral distress levels using the Moral Distress Scale Revised (MDS-R) and its relationship with intention to stay. The study reported in this paper was part of a larger study that also investigated Critical Care nurses' work environment in Canada and the Midlands region of the UK. During January to August 2017 a cross-sectional survey was distributed to adult Critical Care nurses in the Midlands region of the UK. Surveys were distributed to adult Critical Care Registered Nurses in the Midlands region of the UK examining moral distress levels and intention to stay in Critical Care, the organization (NHS Trust) and in the nursing profession. Two hundred sixty-six number of a potential sample of 1066 Critical Care nurses completed the survey (25% response rate). Age and moral distress were significantly positively correlated with intention to stay on their current unit (r=0.16, P=.05), indicating older nurses were more likely to stay in the critical care unit. Moral distress was negatively correlated with intent to stay scores, showing critical care nurses with higher levels of moral distress were less likely to stay on their unit (r=-0.20, P=.02). Moral distress was also significantly negatively correlated with intention to stay with their current employer (r=-0.28, P < .001). Nurses that stated they had high rates of moral distress were more likely to consider leaving their current employer. Moral distress appears to be an issue among adult Critical Care nurses requiring further exploration and development of effective strategies to reduce this phenomenon and stabilize the workforce by reducing turnover. By identifying the top causes of moral distress, tools and strategies can be developed to allow the Critical Care nurse to work within an ethically safe clinical environment and reduce the turnover of experienced adult Critical Care nurses.