Moral Distress Research Articles

Nurses' Well-Being: An Amazing Recipe, But What Ingredients Remain Missing?

The term "system well-being" can move forward a new vision, meaning the result coming from the addition of the well-being of persons belonging to different institutions and organizations, which are all parts of the "health care system." Beginning with this "new definition," with the aim of analyzing the multifaceted issues related to nurses' well-being, we could use the "classical nursing metaparadigm" composed of 4 concepts: "health," "nursing," "environment," and "person." We briefly describe this conceptual map and provide some focused suggestions for further reflection on topics such as physical and psychological well-being, economic gain and career opportunities, work climate, burnout, low job satisfaction, moral distress, compassion fatigue, and a joyful work environment. This view may help organizations to focus on interventions to prevent or eliminate stress, which may be more proactive and effective than interventions to manage stress. Moreover, it offers a multidimensional map to analyze the different aspects influencing the well-being issue, keeping in mind that a concrete solution can be obtained only if all the components of health care systems and society do their part. Some solutions proposed by authors and organizations to increase nurses' well-being are mindfulness based, such as meditation, yoga, acupuncture, gratitude, journaling, choirs, coaching, workload reduction, job crafting, and peer networks. Other reflections on work organization, expected professional behaviors, nurses' retention, and education should be added to the discussion on this multidimensional issue.

Insights into the Impact of Organizational Factors and Burnout on the Employees of a For-Profit Psychiatric Hospital during the Third Wave of the COVID-19 Pandemic

In this paper, we provide insights into the interplay among the organizational, job, and attitudinal factors and employees’ intentions to resign during the third wave of the COVID-19 pandemic at a mental health hospital. We point out shortcomings in the relationship dynamics between executive administration and operational staff and propose a pathway to develop more effective leadership frameworks to increase job satisfaction. We integrate qualitative data from case information and open-ended questions posed to employees at a mental health hospital and quantitative data from a small-scale survey (n = 19). We highlight that the ability to achieve objectives, work autonomy, burnout, affective commitment, distributive and procedural justice, and job satisfaction are critical in determining individuals’ intentions to resign. Individuals identified disconnectedness and moral distress as critical aspects, while highlighting empathy, compassion, satisfaction, and confidence as pivotal elements. Mental healthcare settings could benefit from enhancing the staff’s ability to achieve objectives, work autonomy, affective commitment, and both distributive and procedural justice. Addressing burnout and implementing measures to increase job satisfaction are equally vital. Efficiently restructuring dynamics between various leadership levels and staff can significantly improve employee retention.

Mental health of veterinary nurses and student veterinary nurses: A scoping review.

Research has shown that veterinarians around the world are at high risk of mental health problems, but far less research has examined the mental health of veterinary nurses (VNs) and student veterinary nurses (SVNs). This scoping review aimed to map existing evidence on this topicand identify knowledge gaps. Literature searches of MEDLINE, PsycINFO, PubMed, Web of Science and Google Scholar were conducted, and a structured screening and selection procedure was applied. To be included, studies had to be peer reviewed, report relevant results specific to VNs and/or SVNs,and provide descriptive statistics if using quantitative methods. Of the 2118 publications identified, only 13 journal articles met the inclusion criteria. The findings were summarised in five categories: mental health and wellbeing, burnout, stress, compassion fatigueand moral distress. While the findings of five of the studies suggested that some VNs and SVNs experienced some form of poor mental health, these studies lacked generalisability or transferability for multiple reasons. There was also inconsistency and ambiguity in the interpretation of findings, as well as incompatible or oversimplified definitions of mental health problems. Our review excluded grey literature, such as reports, theses and conference presentations, as a preliminary search found very little empirical research on VNs' and SVNs' mental health in this type of publication. More research is needed to address the gaps in the existing evidence supporting our understanding of VN and SVN mental health. This should establish baseline measures and include comparisons with other occupational and national populations.

Digital ethical reflection in home nursing care: Nurse leaders' and nurses' experiences.

Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care. The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care. The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data. The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities. The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research. Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection. Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses' understanding of the tool's purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work.

Trolling the Leviathan: How the use of social media by democratic organizations engenders monsters

The proliferation of trolls may be one of the main reasons why democratic organizations fail to use social media to renew. The literature predominantly assimilates these trolls to psychologically deviant individuals. This article questions this individual-centric approach by suggesting that trolls may well be socially constructed organizational monsters. To investigate this phenomenon, for 2 years, we studied the interactions on a Facebook group between the leaders and members of a trade union. We identified three bi-directional effects at the heart of what we call the monstrification process: discording, disordering, and disgusting effects. The paper contributes to the troll and organizational monster literature by evidencing the four-stage process through which trolls are organizationally constructed as deviant online participants. Our work also adds to the democratic organization literature by metaphorically underlining actors’ emotional and moral distress caused by the dysfunctional encounter of offline and online democracy.

A latent profile analysis of moral emotions following moral transgressions.

Moral transgressions (MTs), events that violate one's moral code, are associated with the moral emotions of guilt and shame. However, there may be different patterns by which people experience guilt and shame that affect distress following MTs. Undergraduates (N = 1371) exposed to anMT completed self-report assessments. This study used latent profile analysis (LPA) to examine profiles based on guilt cognitions, internalized shame, and distress in relation to a reported MT. Cognitive flexibility, years since the MT, and deliberate and intrusive rumination were examined as variables to determine how these factors predicted profile membership. Results from the LPA revealed a three-profile solution: a low moral distress profile (n = 1002), a moderate moral distress profile (n = 262), and a shame prominent profile (n = 107). Results indicated that higher levels of deliberate and intrusive rumination and lower levels of cognitive flexibility significantly increased the likelihood of belonging to the moderate moral distress or shame prominent profiles compared to the low moral distress profile. Higher levels of intrusive rumination and lower levels of cognitive flexibility also significantly increased the likelihood of belonging to the shame prominent profile over the moderate distress profile. Three different profiles emerged, with the shame prominent profile being driven primarily by internalized shame. Results suggest that intrusive rumination and cognitive inflexibility are risk factors to experiencing adverse responses to MTs.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey.

By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support. A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making. 305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility. Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Measuring moral distress in health professionals using the MMD-HP-SPA scale

BackgroundMoral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes.MethodsA regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice.ResultsThe mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9).ConclusionsFemale, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

Exploration of ‘micro’ level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory

BackgroundMacro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The ‘micro’ level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored. ObjectiveExplore ‘micro’ level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory. MethodA qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique). ResultsThree micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation. ConclusionClinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment (WE CARE): An Evidence-Based Wellness Program.

Poor well-being and burnout among the nursing workforce were heightened by the COVID-19 pandemic. The purpose of this study was to deliver, spread, and sustain an evidence-based wellness program, Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment (WE CARE), for nurse leaders, staff registered nurses (RNs), and patient care technicians (PCTs) to ameliorate or prevent burnout, promote resilience, and improve the work environment. The program included Community Resiliency Model (CRM) training provided by a certified 6-member wellness team. A baseline and 6-month follow-up survey included measures of well-being, moral distress, burnout, resilience, perceived organizational support (POS), job satisfaction, intent to leave (ITL), and work environment. A total of 4900 inpatient RNs, PCTs, and leaders of a 1207-bed academic medical center in the southeastern United States were analyzed. From baseline (n = 1533) to 6-month follow-up (n = 1457), well-being, moral distress, burnout, job satisfaction, and work environment improved; however, resilience, POS, and ITL did not. Although we have seen some improvements in well-being and mental health indicators, it is still early in the intervention period to have reached a critical mass with the training and other interventions. The mental health and work environment issues among nurses are so complex, no one-size-fits-all intervention can resolve.

Medical students’ perceptions of prosocial behaviors: a grounded theory study in China

IntroductionProsocial behavior has been shown to be protective against burnout. Yet, we know little about prosocial behavior in medical students. We wanted to know what are chinese medical students' understanding of prosocial behavior and which factors influence their participation in it?MethodsWe undertook a grounded theory study, following Corbin & Strauss. We used convenience sampling and conducted semi-structured individual interviews. We analyzed data using open, axial, and selective coding techniques. Next, we grouped data into concepts. We noticed these concepts aligned with three existing social theories, so we developed our theory in concert with these: the Theory of Planned Behavior, Self-Determination Theory, and Social Support Theory.ResultsTwenty-eight medical students participated in this study. Medical students hold especial views on the roles of medical physicians, and most of these views align with students' core values, including the value of prosocial behavior. Students are intrinsically motivated to engage in prosocial behaviors that align with their core values. Personal values, personality traits, perceived self-competence, career motivation, environmental factors, and family influences are the core factors influencing medically positive prosocial behavior.ConclusionsThis study supports a focus on prosocial behavior instead of altruistic behavior in medical education. We anticipate that promoting prosocial behavior through medical curricula will reduce moral distress and burnout among medical students.

Positive associations between potentially morally injurious experiences and alcohol outcomes in college students: Results from a dominance analysis.

A novel framework for understanding college students' alcohol use is moral injury-psychological distress that stems from events that violate moral beliefs. Considering the predominantly positive associations between moral injury and alcohol use in military samples, this relationship may extend to students. The purpose of this study was to examine the association between potentially morally injurious experiences (PMIEs), alcohol use, and related consequences. Furthermore, we aimed to determine the relative importance of PMIE subtypes on alcohol outcomes. Participants included 604 college students (78% female; 38% Caucasian) with a mean age of 21 years (SD = 4.44). We hypothesized that (a) the composite PMIE score would be positively associated with alcohol consumption and consequences and (b) Commission with Agency would have the strongest association with alcohol outcomes, followed by Betrayal, Omission, Commission under Duress, posttraumatic stress (PTS) symptoms, and Witnessing. Analyses revealed that PMIEs were positively associated with alcohol-related consequences but not drinks per week when controlling for PTS symptoms. Moreover, the dominance analysis showed that Commission with Agency had the strongest association with consumption, followed by Betrayal, PTS symptoms, Commission under Duress, Witnessing, and Omission. PTS symptoms had the strongest association with alcohol-related consequences, followed by Commission with Agency, Commission under Duress, Omission, Betrayal, and Witnessing. These findings help distinguish moral injury constructs from PTS and highlight the importance of Commission with Agency in analyzing alcohol outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Moral distress and associated factors among nurses working in central Ethiopia: a cross-sectional study

BackgroundMoral distress is recognized as a problem affecting nurse professionals globally. Unaddressed moral distress harms nurses’ physical and mental health, the quality of patient care, and the performance of healthcare teams and organizations. However, evidence on the magnitude and risk factors of moral distress is limited in Ethiopia in general and in the study area in particular. Thus, this study aimed to assess the magnitude of moral distress and associated factors among nurses working in Adama Comprehensive Specialized Hospital Medical College, central Ethiopia, 2023.MethodsA facility-based cross-sectional study was conducted from January 1 to 30, 2023, with 219 nurses. A simple random sampling technique was employed to select the study participants. A self-administered structured questionnaire was used for data collection and Moral Distress Scale-Revised (MDS-R) was used to assess moral distress. Data were checked, coded, and entered into Epi info version 7, and then exported to the Statistical Package for Social Science version 26 for analysis. Bivariable and multivariable logistic regression analyses were carried out to identify factors associated with moral distress. The odds ratio with its 95% confidence interval was used as a measure of association and statistical significance was declared at a p-value < 0.05.ResultA total of 212 nurses participated in the analysis making the response rate 96.8%. The magnitude of moral distress was 86.8% (95% CI 82.1%, 91.0%). Perceived powerlessness (AOR = 6.08; 95% CI 1.69, 11.8), lack of confidence (AOR = 7.08; 95% CI 2.05–14.41), inadequate staffing (AOR = 12.46; 95% CI 3.28,15.1), and perceived weak organizational support (AOR = 11.59; 95% CI 2.8,17.33) were significantly associated with moral distress.ConclusionThe magnitude of moral distress was high among nurses in the study setting. Perceived powerlessness, lack of confidence, inadequate staffing, and perceived weak organizational support were independent determinants of moral distress. Thus, creating adequate number of staff, and establishing acceptable organizational policies are ways to reduce moral distress.

What’s Moral Distress Got to Do With It? How to Avoid Burnout and Optimize Patient Care

Burnout, estimated to affect between 40-80% of healthcare professionals, is a complex issue encompassing emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. The Stanford Model of Professional Fulfillment considers both individual and system-level factors with three main elements of efficiency of practice, personal resilience, and culture of wellness. Dr. Finkelstein’s alternate model for burnout reimagines the Stanford Model with three main factors contributing to burnout: inevitable suffering, moral distress, and “extra junk.” In Dr. Finkelstein’s alternate model, inevitable suffering arises from the emotional toll of providing patient care. While interventions like coaching, therapy, and mindfulness are beneficial, they must be offered genuinely, not as profit-driven schemes. “Extra junk” refers to administrative burdens that take away from patient care. Some initiatives aim to alleviate these burdens, but their effectiveness needs critical evaluation. Finally, moral distress occurs when external constraints hinder an individual’s ethical actions. Burnout affects not just individual professionals but also the entire healthcare system, leading to early retirements, lower quality care, and worsening health outcomes. Recognizing this, the US Surgeon General has outlined an approach to address burnout that requires cultural changes at all levels of the healthcare ecosystem. Healthcare professionals are resilient, and part of the solution lies in individual recognition of burnout, work-life balance, and finding joy in work. However, larger cultural shifts towards justice and equity, both within healthcare and broader society, are needed. This includes prioritizing workforce diversity, humane sick and maternity leave policies, and reducing unnecessary administrative burdens. Academic institutions also have a role in promoting mentorship, recognizing the contributions of underrepresented groups, and supporting burnout research. Addressing burnout effectively requires a comprehensive approach that considers individual and system-level factors, advocating for systemic reforms, and prioritizing justice and equity within the healthcare ecosystem.

Gezamenlijke reflectie over ethische twijfel met CURA: een laagdrempelig instrument voor moreel beraad

Joint reflection on moral doubts with CURA: a low-threshold clinical ethics support instrument Healthcare providers frequently encounter morally challenging situations. Clinical ethics support helps them to navigate in these complex situations by fostering reflection and generating new insights and courses of action. CURA is an instrument developed to provide low-threshold support in situations that evoke moral doubt. This article presents a case study to illustrate how CURA works and to underline the benefits it can bring to healthcare providers. The case involves a woman with Alzheimer’s disease exhibiting restlessness at night, disrupting the sleep of other clients of the residential care center. The night shift nurses want the situation to be resolved, for instance through measures such as fixation. The dementia case manager, however, advocates for an approach that meets her values and the needs of all participants. This case discussion highlights the significance of joint reflection with clinical ethics support: provide good care through generating new courses of action together and reduce moral distress by sharing moral doubts. CURA is one of the methods that can be used to achieve these goals.

Moral Distress and Professional Autonomy among Staff Nurses in Private Hospitals

To optimize nurses' roles, it is essential to minimize moral distress and maximize professional autonomy. However, limited local studies explore the correlation between moral distress and professional autonomy among nurses. This research in Midsayap, Cotabato for Q1 2023 utilized a quantitative approach, revealing that most nurses were young adults (19-35 years old), predominantly female, with a bachelor's degree, and employed in private hospitals. Moral distress was low, and professional autonomy varied. No significant relationships were found between demographic factors and moral distress or professional autonomy. Despite moral distress, high professional autonomy can be achieved, and the two are not significantly related. An autonomy enhancement plan was developed to address the study's findings.

Multicenter investigation of moral distress among physicians and its impact on the intention to leave working position

Introduction: The evidence concerning Moral Distress (MD) among physicians is limited, while such data are absent for physicians working in the Greek National Health System (GNHS). The purpose of this study is the investigation of MD among physicians in Greece and the validation Moral Distress Scale-Revised (MDS-R) as a reliable method for the measurement of MD in the Greek language. Methods: This is a multicenter study in which 200 physicians of all specialties and degrees participated. A self-reporting questionnaire was used. The MDS-R questionnaire is constituted of 21 items that describe conditions met in clinical practice, aiming to investigate the frequency and intensity of such cases. The questionnaire was translated and validated in the Greek language. Results: The test-retest procedure was undergone in a sample of 18 physicians and it was found significant and high agreement in all of the MD scale items. Therefore, all 21 items of the MDS-R questionnaire were found suitable for inclusion in the Greek version of MDS-R. A model of four main factors emerged after the analysis of the results with a total variance of 46,8% and all these factors were correlated with each other. MD was detected to a significant degree in more than half participants. The incidence and intensity of MD were higher in physicians who worked in general hospitals compared to those working in cancer hospitals, which is reported for the first time. Conclusions: The Greek version of MDS-R is a valid and reliable instrument for the investigation of MD among Greek physicians. Moral distress impacts the Greek physicians but the degree depends on the working position. Moral distress is also associated with leaving a working position among Greek physicians.

Interprofessional practice and person-centred care: moral contexts and ethical conflicts in the US and Canada

Health and social care services and systems increasingly promote both interprofessional practice and person-centred care. This discussion first examines the clinical and community-based contexts for providing interprofessional practice and person-centred care through the lens of personal, interpersonal, interprofessional and organisational values. Emerging conflicts among values are highlighted using the concept of moral distress, with examples from US and Canadian settings. The comparison then moves to the systems level, examining different US and Canadian contexts for improving the quality and reducing the cost of care. Finally, implications and applications are presented, focusing on interrelationships among the individual, interprofessional team and organisation.

Editorial: Moral distress and its variations

Editorial: Moral distress and its variations

The Continuum of Moral Harms: Correctional Officers’ Perspectives of Prison and the Influence on their Wellness

AbstractWe apply the continuum of moral harms as described by Litz and King (J Trauma Stress 32:341–349, 2019), ranging from moral distress to moral injury, to understand the impacts of correctional officer (CO) interpretations of prison, recognizing how experiencing prison work informs their personal views. In the current study, we analyze data from 93 COs with a maximum of 2 years of work experience, to understand how, reflecting on their occupational experience, they perceive the purpose of place of their work—the federal penitentiary. Findings reveal prison as a space that they believe should be rehabilitative but which is often adamantly perceived as not rehabilitative. Accordingly, these contradictory circumstances reveal most officers encounter workplace experiences that may be consistent with current conceptualizations of moral frustration, distress, or injury. Thus, we demonstrate how prison work can produce moral challenges for COs. We recommend further study into the conceptualizations of moral harm in prison work more broadly and how to inform proactive strategies to address sources of these deleterious experiences.