Moral Distress Scale-Revised Research Articles

Moral Distress and Intention to Leave the Profession: Lithuanian Nurses in Municipal Hospitals.

The purpose of this study was to describe the level of moral distress experienced by nurses, situations that most often caused moral distress, and the intentions of the nurses to leave the profession. A descriptive, cross-sectional, correlational design was applied in this study. Registered nurses were recruited from five large, urban Lithuanian municipal hospitals representing the five administrative regions in Lithuania. Among the 2,560 registered nurses, from all unit types and specialities (surgical, therapeutic, and intensive care), working in the five participating hospitals, 900 were randomly selected to be recruited for the study. Of the 900 surveys distributed, 612 questionnaires were completed, for a response rate of 68%. Depending on the hospital, the response rate ranged from 61% to 81%. Moral distress was measured using the Moral Distress Scale-Revised (MDS-R). The MDS-R is designed to measure nurses' experiences of moral distress in 21 clinical situations. Each of the 21 items is scored using a Likert scale (0-4) in two dimensions: how often the situation arises (frequency) and how disturbing the situation is when it occurs (intensity). On the Likert scale, 0 correlates to situations that have never been experienced, and 4 correlates to situations that have occurred very often. Among the 612 participants, 206 (32.3%) nurses reported a low level of moral distress (mean score 1.09); 208 (33.9%) a moderate level of distress (mean score 2.53), and 207 (33.8%) a high level of distress (mean score 3.0). The most commonly experienced situations that resulted in moral distress were as follows: "Carrying out physician's orders for what I consider to be unnecessary tests and treatments" (mean score 1.66); "Follow the family's wishes to continue life support even though I believe it is not in the best interest of the patient" (mean score 1.31); and "Follow the physician's request not to discuss the patient's prognosis with the patient or family" (mean score 1.26). Nurses who had a high moral distress level were three times more likely to consider leaving their position compared with respondents who had a medium or low moral distress level (8.7% and 2.9%, respectively; p < .05). Our findings provide evidence on the association between moral distress and intention to leave the profession. Situations that may lead health professionals to be in moral distress seem to be mainly related to the unethical work environment. The findings of this study reported that moral distress plays a role in both personal and organizational consequences, including negative emotional impacts upon employees.

Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals

Background: As ongoing research explores the impact of moral distress on health care professionals (HCPs) and organizations and seeks to develop effective interventions, valid and reliable instruments to measure moral distress are needed. This article describes the development and testing of a revision of the widely used Moral Distress Scale–Revised (MDS-R) to measure moral distress. Methods: We revised the MDS-R by evaluating the combined data from 22 previous studies, assessing 301 write-in items and 209 root causes identified through moral distress consultation, and reviewing 14 recent publications from various professions in which root causes were described. The revised 27-item scale, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), is usable by all HCPs in adult and pediatric critical, acute, or long-term acute care settings. We then assessed the reliability of the MMD-HP and evaluated construct validity via hypothesis testing. The MMD-HP, Hospital Ethical Climate Survey (HECS), and a demographic survey were distributed electronically via Qualtrics to nurses, physicians, and other health care professionals at two academic medical centers over a 3-week period. Results: In total, 653 surveys were included in the final analysis. The MMD-HP demonstrated good reliability. The four hypotheses were supported: (1) MMD-HP scores were higher for nurses (M 112.3, SD 73.2) than for physicians (M 96.3, SD 54.7, p = 0.023). (2) MMD-HP scores were higher for those considering leaving their position (M 168.4, SD 75.8) than for those not considering leaving (M 94.3, SD 61.2, p < 0.001). (3) The MMD-HP was negatively correlated with the HECS (r = –0.55, p < 0.001). (4) An exploratory factor analysis revealed a four-factor structure, reflective of patient, unit, and system levels of moral distress. Conclusions: The MMD-HP represents the most currently understood causes of moral distress. Because the instrument behaves as would be predicted, we recommend that the MMD-HP replace the MDS-R.

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Moral distress in paediatric oncology: Contributing factors and group differences.

Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress. To explore healthcare professionals' experiences of situations that generate moral distress in Swedish paediatric oncology. 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. 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%. 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. 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. 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. 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.

Palliative Care Consultation Policy Change and Its Effect on Nurses' Moral Distress in an Academic Medical Center.

Moral distress affects workplace environment, burnout, employee retention, and patient safety. Palliative care is frequently involved in complex care for patients that may cause moral distress among staff. The goal of this study was to measure change in moral distress among nurses after implementation of a policy that allows nurses to consult palliative care. Before the policy change, data were gathered via email using the Moral Distress Scale-Revised. The scale was redistributed 6 months after implementation of the consult policy. Pre and post Moral Distress Scale-Revised results were analyzed. Qualitative thematic analyses of the nurses' comments were conducted.A significantly lower percentage of nurses reported providing care for a hopelessly ill patient frequently or very frequently (34.6% vs 23.1%, P = .0397) after the policy change. However, a significantly higher percentage of nurses postpolicy reported frequently or very frequently providing less-than-optimal care because of pressures from administrators/insurers (14.4% vs 21.1%, P = .0378), caring for patients they did not feel qualified to care for (5.3% vs 14.8%, P = .0055), and working with providers who were not competent to care for the patient (13.9% vs 26.9%, P = .0059). Themes from nurses' comments were inadequate staffing, communication, ethical concerns, and lack of education.

Relationships Among Palliative Care, Ethical Climate, Empowerment, and Moral Distress in Intensive Care Unit Nurses.

Intensive care unit nurses experience moral distress when they feel unable to deliver ethically appropriate care to patients. Moral distress is associated with nurse burnout and patient care avoidance. To evaluate relationships among moral distress, empowerment, ethical climate, and access to palliative care in the intensive care unit. Intensive care unit nurses in a national database were recruited to complete an online survey based on the Moral Distress Scale-Revised, Psychological Empowerment Index, Hospital Ethical Climate Survey, and a palliative care delivery questionnaire. Descriptive, correlational, and regression analyses were performed. Of 288 initiated surveys, 238 were completed. Participants were nationally representative of nurses by age, years of experience, and geographical region. Most were white and female and had a bachelor's degree. The mean moral distress score was moderately high, and correlations were found with empowerment (r = -0.145; P = .02) and ethical climate scores (r = -0.354; P < .001). Relationships between moral distress and empowerment scores and between moral distress and ethical climate scores were not affected by access to palliative care. Nurses reporting palliative care access had higher moral distress scores than those without such access. Education, ethnicity, unit size, access to full palliative care team, and ethical climate explained variance in moral distress scores. Poor ethical climate, unintegrated palliative care teams, and nurse empowerment are associated with increased moral distress. The findings highlight the need to promote palliative care education and palliative care teams that are well integrated into intensive care units.

Abstract P-333: MORAL DISTRESS IN CANADIAN PAEDIATRIC AND NEONATAL ICU: A NATIONAL SURVEY

Aims & Objectives: The extent of moral distress (MD) experienced by Canadian Paediatric and Neonatal ICU providers is unknown. Our aim is to quantify MD, depersonalization (DP), uncertainty of treatment effect and describe demographic associations in providers. Methods Survey of Canadian neonatal and paediatric ICU providers using the Moral Distress Scale–Revised (MDS-R), Mishel’s Uncertainty Scale and Maslach Burnout Inventory to measure MD, treatment uncertainty and depersonalization (DP). Results are presented as counts (%) or median (IQR). Results 49(91%) of 54 eligible ICUs provided 2822(94%) usable responses with overall response rate of 42%. Respondents were mostly female 2626 (93%); RNs 1825(65%); fulltime 1829(65%) and from NICU 1866(66%). Overall MDS-R scores were 79 (52–113) and were similar in NICUs 79(52–114) and PICUs 79(52–114); full and part-time; and in trainees and non-trainees. Scores differed by discipline: RN 85(57–121); RT 76.5(50–113); and MD 60(41–85) (p<0.0001). Females 81(54–116) scored higher than males 63(42–100) (p<0.0001). Uncertainty scores were 11 (9–13). Each unit increase was associated with 4-unit increase in MDS-R scores (p<0.0001). DP scores were 6 (3–11). Respondents with high DP scores 633 (22%) had higher MDS-R scores 108 (76–142) (p<0.0001). DP scores increased with years of experience from 1 yr (18%), peaking at 5-9yrs (29%) and falling to 12% >30yrs. Conclusions We found higher MDS-R scores in females, RN and RRTs. The clinical relevance of MD is supported by the positive correlation found with DP. Greater uncertainty about treatment effect was associated with MD. This suggests that uncertainty may be an important determinant of MD and further methodologic work is needed.

Reflective Debriefing: A Social Work Intervention Addressing Moral Distress among ICU Nurses

ABSTRACTHealth-care workers may experience moral distress when they are unable to act as they believe is ethically appropriate in their clinical work. A social worker-facilitated protocol called Reflective Debriefing was developed and tested for alleviating moral distress through regular debriefings with nursing staff on an intensive care unit (ICU). Forty-two ICU nurses completed a Moral Distress Scale-Revised (MDS-R) at the beginning and end of a 6-month period, during which time regular debriefings were offered. The overall level of moral distress on the ICU surveyed was found to be low to moderate. The top three most frequent situations causing moral distress reported by most nurses in this study were related to the provision of nonbeneficial care in the ICU. Participants reported gaining the most benefit from feeling empowered to constructively confront other staff members about truth-telling in giving a prognosis. Nurses’ overall response to the intervention was positive, with 100% of participants requesting to continue the Reflective Debriefing sessions either on a monthly or on an as-needed basis. The response to the intervention emphasized the importance of interprofessional collaboration to successfully combat moral distress among health-care workers and may protect them from burnout, detachment, and even quitting their profession.

Cross-cultural adaptation and validation of the Moral Distress Scale-Revised for nurses.

Cross-culturally adapt and validate the Moral Distress Scale-Revised for nurses. Quantitative, analytical cross-sectional study conducted with 157 nurses of two hospital institutions of Southern Brazil, one public and one philanthropic. Procedures conducted: cultural adaptation of the instrument according to international recommendations; validation for the Brazilian context. Face and content validation was considered satisfactory as assessed by a specialist committee and a pretest. The instrument demonstrated satisfactory internal consistency through frequency and intensity analysis per question in the 157 items and per subgroups of the various hospital units. Cronbach's alpha was 0.88 for the instrument and between 0.76 and 0.94 for hospital units. Pearson's correlation found a moderate association for moral distress among nurses. The Moral Distress Scale-Revised - Brazilian version is a valid instrument for the assessment of moral distress in nurses. Adaptar culturalmente e validar a Moral Distress Scale Revised para enfermeiros. Estudo quantitativo, transversal analítico, realizado com 157 enfermeiros de duas instituições hospitalares do Sul do Brasil, uma pública e uma filantrópica. Realizou-se: a adaptação cultural do instrumento segundo recomendações internacionais; e a sua validação para o contexto brasileiro. A validade de face e conteúdo foi considerada satisfatória mediante avaliação de comitê de especialistas e realização de pré-teste. Mediante análise de frequência e intensidade por questão nos 157 questionários e por subconjuntos das diferentes unidades hospitalares, o instrumento demonstrou consistência interna satisfatória, com alfa de Cronbach 0,88 para o instrumento e entre 0,76 e 0,94 para as unidades hospitalares. A correlação de Pearson identificou moderada associação de sofrimento moral nos enfermeiros. o Moral Distress Scale Revised - versão brasileira é um instrumento válido para ser utilizado na avaliação de sofrimento moral de enfermeiros.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover.

The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital. Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale-Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one's professional quality of life. Relationships between these constructs and clinicians' years in health care, critical care patient load, and professional discipline were explored. The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%. The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted. (PsycINFO Database Record

Value congruence and depressive symptoms among critical care clinicians: The mediating role of moral distress.

Clinicians working in intensive care units are often exposed to several job stressors that can negatively affect their mental health. Literature has acknowledged the role of value congruence and job control in determining clinicians' psychological well-being and depressive symptoms. However, potential mediators of this association have been scarcely examined. This study aimed to test the mediating role of moral distress in the relationship between value congruence and job control, on the one hand, and depression, on the other hand. A cross-sectional study involving physicians, nurses, and residents working in 7 intensive care units in the north of Italy was conducted. Clinicians were administered in the Italian Moral Distress Scale-Revised, the value and control subscales of the Areas of Worklife Scale, and the Beck Depression Inventory II. Structural equation modeling was used to test the mediation model. Analysis on 170 questionnaires (response rate 72%) found no relations between job control and moral distress. A total indirect effect of value congruence on depression through moral distress (β=-.12; p=.02) was found. Moral distress contributes to the development of depressive symptoms among critical care clinicians who perceive a value incongruence with their organization and therefore should be addressed.

Moral distress and its contribution to the development of burnout syndrome among critical care providers

BackgroundBurnout appears to be common among critical care providers. It is characterized by three components: emotional exhaustion, depersonalization and personal accomplishment. Moral distress is the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. We aimed to estimate the correlation between moral distress and burnout among all intensive care unit (ICU) and the step-down unit (SDU) providers (physicians, nurses, nurse technicians and respiratory therapists).MethodsA survey was conducted from August to September 2015. For data collection, a self-administered questionnaire for each critical care provider was used including basic demographic data, the Maslach Burnout Inventory (MBI) and the Moral Distress Scale-Revised (MDS-R). Correlation analysis between MBI domains and moral distress score and regression analysis to assess independent variables associated with burnout were performed.ResultsA total of 283 out of 389 (72.7%) critical care providers agreed to participate. The same team of physicians attended both ICU and SDU, and severe burnout was identified in 18.2% of them. Considering all others critical care providers of both units, we identified that overall 23.1% (95% CI 18.0–28.8%) presented severe burnout, and it did not differ between professional categories. The mean MDS-R rate for all ICU and SDU respondents was 111.5 and 104.5, respectively, p = 0.446. Many questions from MDS-R questionnaire were significantly associated with burnout, and those respondents with high MDS-R score (>100 points) were more likely to suffer from burnout (28.9 vs 14.4%, p = 0.010). After regression analysis, moral distress was independently associated with burnout (OR 2.4, CI 1.19–4.82, p = 0.014).ConclusionsMoral distress, resulting from therapeutic obstinacy and the provision of futile care, is an important issue among critical care providers’ team, and it was significantly associated with severe burnout.

Moral Distress in Nurses Providing Direct Patient Care at an Academic Medical Center.

Moral distress is the psychological response to knowing the appropriate action but not being able to act due to constraints. Previous authors reported moral distress among nurses, especially those that work in critical care units. The aims of this study were: (1) to examine the level of moral distress among nurses who work at an academic health system, (2) to compare the level of moral distress in nurses who work across specialty units at an academic health system, (3) to compare moral distress by the demographic characteristics of nurses and work experience variables, and (4) to identify demographic characteristics and type of clinical setting that may predict which nurses are at high risk for moral distress. A cross-sectional survey design was used with staff nurses who work on inpatient units and ambulatory units at an academic medical center. The moral distress scale-revised (MDS-R) was used to assess the intensity and frequency of moral distress. The overall mean MDS-R score in this project was low at 94.97 with mean scores in the low to moderate range (44.57 to 134.58). Nurses who work in critical care, perioperative services, and procedure areas had the highest mean MDS-R scores. There have been no previous reports of higher scores for nurses working in perioperative and procedure areas. There was weak positive correlation between MDS-R scores and years of experience (Rho = .17, p = .003) but no correlation between age (Rho = .02, p = .78) or education (Rho = .05, p = .802) and moral distress. Three variables were found useful in predicting moral distress: the type of unit and responses to two qualitative questions related to quitting their job. Identification of these variables allows organizations to focus their interventions.

Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised.

Moral distress is a common experience among critical care professionals, leading to frustration, withdrawal from patient care, and job abandonment. Most of the studies on moral distress have used the Moral Distress Scale or its revised version (Moral Distress Scale-Revised). However, these scales have never been validated through factor analysis. This article aims to explore the factorial structure of the Moral Distress Scale-Revised and develop a valid and reliable scale through factor analysis. Validation study using a survey design. Eight medical-surgical ICUs in the north of Italy. A total of 184 clinicians (64 physicians, 94 nurses, and 14 residents). The Moral Distress Scale-Revised was translated into Italian and administered along with a measure of depression (Beck Depression Inventory-Second Edition) to establish convergent validity. Exploratory factor analysis was conducted to explore the Moral Distress Scale-Revised factorial structure. Items with low (less than or equal to 0.350) or multiple saturations were removed. The resulting model was tested through confirmatory factor analysis. The Italian Moral Distress Scale-Revised is composed of 14 items referring to four factors: futile care, poor teamwork, deceptive communication, and ethical misconduct. This model accounts for 59% of the total variance and presents a good fit with the data (root mean square error of approximation = 0.06; comparative fit index = 0.95; Tucker-Lewis index = 0.94; weighted root mean square residual = 0.65). The Italian Moral Distress Scale-Revised evinces good reliability (α = 0.81) and moderately correlates with Beck Depression Inventory-Second Edition (r = 0.293; p < 0.001). No significant differences were found in the moral distress total score between physicians and nurses. However, nurses scored higher on futile care than physicians (t = 2.051; p = 0.042), whereas physicians scored higher on deceptive communication than nurses (t = 3.617; p < 0.001). Moral distress was higher for those clinicians considering to give up their position (t = 2.778; p = 0.006). The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.

To change or not to change - translating and culturally adapting the paediatric version of the Moral Distress Scale-Revised (MDS-R)

BackgroundPaediatric cancer care poses ethically difficult situations that can lead to value conflicts about what is best for the child, possibly resulting in moral distress. Research on moral distress is lacking in paediatric cancer care in Sweden and most questionnaires are developed in English. The Moral Distress Scale-Revised (MDS-R) is a questionnaire that measures moral distress in specific situations; respondents are asked to indicate both the frequency and the level of disturbance when the situation arises. The aims of this study were to translate and culturally adapt the questionnaire to the context of Swedish paediatric cancer care. In doing so we endeavoured to keep the content in the Swedish version as equivalent to the original as possible but to introduce modifications that improve the functional level and increase respondent satisfaction.MethodsThe procedure included linguistic translation and cultural adaptation of MDS-R’s paediatric versions for Physicians, Nurses and Other Healthcare Providers to the context of Swedish paediatric cancer care. The process of adjustment included: preparation, translation procedure and respondent validation. The latter included focus group and cognitive interviews with healthcare professionals in paediatric cancer care.ResultsTo achieve a Swedish version with a good functional level and high trustworthiness, some adjustments were made concerning design, language, cultural matters and content. Cognitive interviews revealed problems with stating the level of disturbance hypothetically and items with negations caused even more problems, after having stated that the situation never happens.ConclusionsTranslation and cultural adaptation require the involvement of various types of specialist. It is difficult to combine the intention to keep the content as equivalent to the original as possible with the need for modifications that improve the functional level and increase respondent satisfaction. The translated and culturally adapted Swedish MDS-R seems to have equivalent content as well as improved functional level and respondent satisfaction. The adjustments were made to fit paediatric cancer care but it could be argued that the changes are relevant for most areas of paediatric care of seriously ill patients.

Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU.

This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer (MDT) scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised (MDS-R), were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p = 0.015), a statistically significant increase in both code status changes DNR (11% control, 28% PEACE, p = 0.013), and in-hospital death (9% control, 25% PEACE, p = 0.015), with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients.

Addressing Moral Distress in Critical Care Nurses: A Pilot Study

Background: Moral distress can affect critical care nurses caring for complex patients. It can result in job dissatisfaction, loss of capacity for caring, and nurse turnover, resulting in a negative impact on quality care. Aim: This study purpose was to determine how moral distress impacts critical care nurses (adult and pediatric) and to implement improvement strategies to reduce moral distress, improve job satisfaction, and retention. Theoretical framework: Nathaniel’s Theory of Moral Reckoning was the grounded theory used to show the application of the improvement interventions. Methods: Phase 1 was a cross-sectional design using the 26-item Hospital Ethical Climate Survey (HECS) and the 21-item Moral Distress Scale-Revised (MDS-R). Phase 2 consisted of a mixedmethod design employing focus group interviews, interventions, and pre- and posttest. Results: Pediatric nurses reported lower mean moral distress composite scores 21.71 (15.47) as compared to the adult nurses 88.75 (64.7). For adult nurses, a strong correlation existed between ethical climate and moral distress (r s = -0.62, n = 10, p = 0.05), with high levels of ethical climate associated with lower levels of moral distress. The cohort group identified personal and professional impact of moral distress with some differences between the pediatric and adult nurses related to the source of moral distress responses to suffering. The 3-month post survey showed a total moral distress score for one adult critical care nurse decreased from 158 to 74. The remaining three nurses’ scores were unchanged. All four nurses were not considering leaving their position now. All participants either agreed or strongly agreed the education and action plan reduced their moral distress. Conclusion: A blended-learning training to include American Association of Critical Care Nurses’ (AACN) 4As, communication and ethical reasoning skills, and personal action plans helped manage moral distress, aided retention, and improved satisfaction of critical care nurses.

Spiritual well-being and moral distress among Iranian nurses.

Moral distress is increasingly recognized as a problem affecting healthcare professionals, especially nurses. If not addressed, it may create job dissatisfaction, withdrawal from the moral dimensions of patient care, or even encourage one to leave the profession. Spiritual well-being is a concept which is considered when dealing with problems and stress relating to a variety of issues. This research aimed to examine the relationship between spiritual well-being and moral distress among a sample of Iranian nurses and also to study the determinant factors of moral distress and spiritual well-being in nurses. A cross-sectional, correlational design was employed to collect data from 193 nurses using the Spiritual Well-Being Scale and the Moral Distress Scale-Revised. This study was approved by the Regional Committee of Medical Research Ethics. The ethical principles of voluntary participation, anonymity, and confidentiality were considered. Mean scores of spiritual well-being and moral distress were 94.73 ± 15.89 and 109.56 ± 58.70, respectively. There was no significant correlation between spiritual well-being and moral distress (r = -.053, p = .462). Marital status and job satisfaction were found to be independent predictors of spiritual well-being. However, gender and educational levels were found to be independent predictors for moral distress. Age, working in rotation shifts, and a tendency to leave the current job also became significant after adjusting other factors for moral distress. This study could not support the relationship between spiritual well-being and moral distress. However, the results showed that moral distress is related to many elements including individual ideals and differences as well as organizational factors. Informing nurses about moral distress and its consequences, establishing periodic consultations, and making some organizational arrangement may play an important role in the identification and management of moral distress and spiritual well-being.

병원간호사의 한국어판 도덕적 고뇌 측정도구의 타당도와 신뢰도

Purpose To develop and test the validity and reliability of the Korean version of the Moral Distress Scale-Revised (KMDS-R) to assess its applicability to Korean hospital nurses. Methods The KMDS-R was articulated through forward-backward translation methods. Internal consistency reliability, construct and criterion validity was calculated using SPSSWIN(19.0). Survey data were collected from 188 nurses from a university hospital in Gangwon-do, South Korea. Results The KMDS-R showed reliable internal consistency with a Cronbach's alpha of .69-.87 and a Guttman Split-half of .69-.82 for the total scale. Factor loading of the 21 items on the five subscales ranged from .41-.80. The KMDS-R was validated by factor analysis and explained 63% of moral distress for Korean hospital nurses. Criterion validity compared to Yoo's MDS showed significant correlation. Conclusion The results suggest promising evidence of the KMDS-R’s reliability and validity. It is used to measure moral distress for Korean hospital nurses. Keywords: Nurses, Moral distress, Validity and Reliability 주요어: 간호사, ë„ë•ì  ê³ ë‡Œ, 타당도와 ì‹ ë¢°ë„

Moral Distress Scale for Occupational Therapists: Part 1. Instrument Development and Content Validity.

We describe the development of an instrument to measure moral distress experienced by occupational therapists and show how its content validity was established. Written comments (n = 78) from a previous survey using the Moral Distress Scale-Revised-Other Health Provider Adult were used to modify that instrument and create the Moral Distress Scale-Revised-Occupational Therapy-Adult Settings (MDS-R-OT[A]). The MDS-R-OT[A] was distributed to a nationwide random sample of 400 occupational therapists who rated the relevance of each item to their clinical practice. A scale content validity index of 81.8% was found (geriatric = 81.5%, physical disability = 80.8%, combination of the two = 85.7%). The MDS-R-OT[A] possesses acceptable content validity and is appropriate for use with occupational therapists working in geriatric or physical disability settings.