Levels Of Moral Distress Research Articles

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.

Examining the effect of moral resilience on moral distress.

The study aims to test the Turkish validity and reliability of the Rushton Moral Resilience Scale (RMRS) and examine the effect of moral resilience on moral distress. Moral distress is a phenomenon that negatively affects health workers, health institutions, and the person receiving care. In order to eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience involves developing systems that support a culture of ethical practice in healthcare and aim to increase an individual's capacity to cope with moral challenges. A methodological and descriptive-predictive study design was adopted. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals (MMD-HP), and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 255 clinical nurses were recruited. Hacettepe University's non-interventional ethics committee approved the study's protocol and informed consent was obtained from the participants. The original four-factor structure of the scale was tested with confirmatory factor analysis, and the index values were evaluated and found at an acceptable level. The Cronbach Alpha coefficient of the scale was found to be 0.826. Moral resilience predicted moral distress total, intensity, and frequency levels. A moderate and weak relationship was found in the negative between all sub-dimensions of moral distress and moral resilience. The Rushton Moral Resilience Scale Turkish version showed good psychometric properties. Moral resilience has a reducing effect on moral distress. Young nurses who have less experience are at risk because they have lower moral resilience levels, while nurses working in intensive care units are at risk because of their high moral distress levels. A healthy workplace can be created by developing specific approaches to improve moral resilience in reducing the impact of moral distress in the healthcare environment.

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 in midwifery practice: A Delphi study

BackgroundMoral distress is a psychological concept that describes the harm associated with actions or inactions that oppose an individuals’ moral beliefs. Moral distress is linked to moral compromise in the workplace that may negatively impact mental wellbeing. Current tools available to assess moral distress are not specific for the Australian health care system or midwifery practice. AimThe aim of this study was to develop a list of situational and outcome statements associated with moral compromise and levels of moral distress in midwifery to inform the development of a tool to measure levels of moral distress in midwives. MethodsThis e-Delphi study was the third stage of a sequential exploratory mixed-methods study. Using an online strategy, three iterative rounds of e-Delphi were collected and analysed for consensus on situations leading to moral distress and the associated psychological outcomes. FindingsTwenty participants contributed across the three rounds. Consensus was met in 40 morally compromising situation statements. The highest level of consensus related to excessive workloads and the associated negative impact of this on women and families. Consensus on outcomes following exposure to morally distressing situations led to the development of a continuum scale from moral frustration to moral injury. Discussion/conclusionThis is the first study to use a consensus method to establish different levels of moral compromise, frustration, distress, and injury in midwifery practice. The findings of this study contribute to a growing body of literature that supports the concept of moral distress occurring across a continuum.

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.

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.

Moral Distress in the ICU: Measuring, Tracking, and Responding to Staff Experiences

Until the surges of COVID-19 patients overwhelmed our health care system, moral distress was largely unknown outside of health care. We conducted a study in a 36-bed intensive care unit (ICU) over an 8-week period to determine the severity and contributing factors to clinicians’ moral distress and how their moral distress impacted intent to leave, and to assess utilization of resources to mitigate the problem. This article describes the level of moral distress experienced by ICU staff, the disparity between hospital-provided resources and the contributing factors of moral distress, and the potential financial cost of job turnover due to moral distress.

The Nurses' Second Victim Syndrome and Moral Distress.

The increasing prevalence of moral distress in the stressful environment of the intensive care unit (ICU) provides grounds for nursing error and endangers patients' health, safety, and even life. One of the most important reasons for this distress is the treatment team's second victim syndrome (SVS), especially nurses, following errors in the treatment system. The present study aimed to determine the relationship between moral distress and SVS in ICUs. This cross-sectional study involved a sample size of 96 ICU nurses working in hospitals affiliated with Tehran University of Medical Sciences, Iran, in the 2021-2022 period, who were selected via a simple random sampling method. Data were collected using the Demographic Questionnaire, the second victim experience and support tool (SVEST) and Moral Distress Scale-Revised (MDS-R). Descriptive statistics (percentage, frequency, mean, and SD) and analytical tests (Spearman correlation coefficient test, independent t-test, and ANOVA) were employed for data analysis. This study used a sample size of 96 intensive care unit nurses working in hospitals affiliated to Tehran University of Medical Sciences selected by simple random sampling. The study obtained research ethics approval, and all participants were informed of the voluntary and anonymous nature of their participation. The results showed that 59.4% of nurses suffered a low level of moral distress, and 40.6% suffered from a moderate level of moral distress. The SVS score of 86.5% of the nurses was moderate. There was no significant and direct correlation between moral distress and SVS in nurses; however, there was a significant and inverse correlation between the moral distress intensity and SVS (p = 0.011). Despite no significant correlation between moral distress and SVS, these variables were at moderate levels. Accordingly, it is suggested to provide a proper ground for expressing morally stressful situations, counseling and training strategies to deal with moral distress, creating support resources for those suffering from SVS, and implementing empowerment programs.

Another Pandemic


 The SARS-CoV-2 pandemic has transgressed biomedical categories. According to Horton, it turned out to be a 'syndrome' that infected virtually all spheres of social life. The pandemic has created toxic social atmosphere highly unfavorable to clinical and clinic-ethical decision making. Constraints and pressures related to micro-, meso-, exo- and macro-environments framing doctors, nurses, and medical students in training were identified. These factors exacerbated moral distress (moral injury) amongst clinicians. In a joint Polish-Lithuanian project (IDUB 2020-2022) we examined predictors of moral distress in pandemic clinical contexts. A survey-based, real-time, correlational and comparative study was conducted in Poland and Lithuania after the first year of pandemic with N=227 participants. Unexpected differences on regular and pandemic-type moral distress levels were found between the two national samples. Polish participants showed significantly higher moral distress levels than their Lithuanian counterparts. The following article discusses these findings and recommends the reinforcement of resilient medical decision making. 

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.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study.

To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. Interview-based qualitative study using inductive thematic analysis. Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Exploration of California School Nurse perspectives on the impact of COVID-19.

To explore in a sample of school nurses (SN) in California the impact of the COVID-19 pandemic on school nurse health services, how school nurses mitigated the impact of COVID-19, and moral distress levels among school nurses. Nineteen (N=19) school nurses who work in K-12 schools in California, USA participated in a mixed-methods approach involving qualitative descriptive design, inductive content analysis, and descriptive statistics. Interviews were conducted in August and September 2021. Five themes emerged: (1) role of the SN during the COVID-19 pandemic, (2) coordination with school administration, (3) COVID-19 related challenges and disruptions to care, (4) moral distress, and (5) coping during the pandemic. The pandemic had a profound impact on school nurses. This study provides school nurse perspectives of the impact of COVID-19 on services they delivered, the unique skills of school nurses essential to mitigation strategies, and moral distress school nurses encountered during the pandemic. Understanding the important role school nurses had during the pandemic is paramount to fully contextualize the contributions they made within public health nursing practice and inform preparedness for future pandemics.

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.

Burnout, compassion fatigue and moral distress in veterinary professionals

Veterinary professionals are becoming increasingly exposed to, and concerned about, burnout, compassion fatigue and moral distress. Work-related stress can have a significant impact on quality of life and contribute to poor mental health. Several studies have shown that emotional exhaustion and mental health illnesses are significantly higher among veterinary surgeons, with the rate of suicide in the veterinary profession four times the rate in the general public. There is an abundance of evidence in the human healthcare field regarding burnout, compassion fatigue and moral distress, but there is very little research in the veterinary field. This study aimed to investigate whether veterinary professionals in the UK are experiencing burnout, compassion fatigue and moral distress, identify possible contributing factors, and ascertain whether veterinary professionals are able to recognise these conditions and have the tools to deal with them. The study found that veterinary professionals showed moderate levels of burnout and compassion fatigue, despite moderate levels of compassion satisfaction. Veterinary surgeons, patient care assistants and veterinary receptionists experienced low levels of moral distress, but registered veterinary nurses experienced moderate levels of moral distress.

The relationship between emotional labor level and moral distress.

The coronavirus disease (COVID-19) pandemic has implications for health professionals. The aim of this study was to explain the relationship between emotional labor levels and moral distress in health professionals during the COVID-19 pandemic using the Structural Equation Modeling (SEM) technique. A descriptive and cross-sectional study was adopted. Data were collected between 7 February and 7 March 2021. 302 health professionals who were not on leave (annual leave, sick leave, prenatal and postnatal leave, etc.) at the time of the research and who volunteered to participate in the research were included. Research data were collected using a "Personal Information Form," the "Emotional Labor Scale" and the "Moral Distress Thermometer." The Ethics Committee approved the study (dated 07.01.2021 and numbered 2021/1-3). The participants were informed of the study aim and written consent was obtained before completing the survey. In the present study, the mediator role of emotional labor in the effect of providing service to a patient with COVID-19 and having had COVID-19 on moral distress was examined in health professionals and it was found that there was a correlation between providing service to a patient with COVID-19 and moral distress regardless of whether or not emotional labor had a role in this relationship. In this study, the relationship between the level of emotional labor and moral distress in health professionals during the COVID-19 pandemic was evaluated with a structural equation model.

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.

Moral Distress Under Structural Violence: Clinician Experience in Brazil Caring for Low-Income Families of Children with Severe Disabilities.

Rigorous attention has been paid to moral distress among healthcare professionals, largely in high-income settings. More obscure is the presence and impact of moral distress in contexts of chronic poverty and structural violence. Intercultural ethics research and dialogue can help reveal how the long-term presence of morally distressing conditions might influence the moral experience and agency of healthcare providers. This article discusses mixed-methods research at one nongovernmental social support agency and clinic in Rio de Janeiro, Brazil. Chronic levels of moral distress and perceptions of moral harm among clinicians in this setting were both violent, following Nancy Scheper-Hughes' use of that term, and a source of exceptional and innovative care. Rather than glossing over the moral variables of work in such desperate extremes, ethnography in these settings reveals novel skills and strategies for managing moral distress.

Moral Distress and Moral Resilience of Health Professionals in a Greek Public Hospital during the Second Wave of Pandemic

Healthcare professionals during the pandemic in the Greek public healthcare system have experienced increased psychological distress, fear and a greater intention to quit their jobs. This study analyzes the factors of moral distress and moral resilience of healthcare professionals employed during the second wave of the pandemic. The target group was the healthcare professionals (HP = 169) who served in the Evaggelismos General Hospital Covid-clinics and -ICU for 2022 and data were collected through life protocols. Healthcare professionals believe that when faced with moral challenges, they are able to discern them and think clearly. They are especially stressed when they care for more patients than they can safely handle when they are involved in care that causes unnecessary suffering or does not adequately relieve pain or symptoms, and when they notice that patient care is getting worse. Also stressful are the situations, leading to the creation of possible moral distress, when they witness a violation of a standard of practice or moral code. Factors that lead or may lead healthcare professionals to moral distress are nursing safety, unnecessary and deteriorating patient care, and violation of medical confidentiality, violation of standards of practice or moral codes. The score on the MMD-HP scale indicates low-to-moderate levels of moral distress. Based on the RMRS scale the moral resilience of healthcare professionals is characterized by moderate-to-high with the highest scores per statement seen when patient care is getting worse and feel pressured to ignore situations where patients have not been given adequate information. The healthcare professionals report that they have either left or have considered leaving their position in a clinic due to moral distress, although they are not currently thinking of leaving their position. The factors that increase the frequency of moral distress and decrease their moral resilience are feeling powerless anxiety, nursing/treatment errors, aggressive treatment, caring for more patients than they can handle, substandard patient care, and hierarchical teams.