Source Of Moral Distress Research Articles

Moral distress in nurses in developing economies: an integrative literature review.

Moral distress has been extensively studied in developed economies; however, not much in terms of studies has been carried out in developing economies. To review the literature reporting the experience of moral distress in nurses in health care settings in developing economies. An integrative literataure review was used. Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online Cochrane and Psych INFO were searched to retrieve titles and abstracts of papers on the experience of moral distress in nurses in developing economies. Sixteen articles reporting the experience of moral distress in nurses in developing economies published between 1984 and March 2019 were used for the review. Analysis of the findings revealed seven themes, nurses' experience of moral distress, inadequate material and human resources, end-of-life challenges, cultural and religious beliefs as a source of moral distress, perceived inactions of medical and nursing staff, impact of moral distress on nurses in developing economies and coping strategies. There is paucity of empirical studies on moral distress in nurses in developing economies. More qualitative studies are needed in various cultural settings to enhance its understanding in nurses working in developing economies.

Financial medicine as a source of moral distress: An unrecognised pathway to moral injury in the South African EMS systems

IntroductionThe phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury. MethodsThis study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. ResultsThe sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list. ConclusionUnderstanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.

Moral Distress in Radiology: Frequency, Root Causes, and Countermeasures-Results of a National Survey.

BACKGROUND. A major cause of burnout is moral distress: when one knows the right course of action but institutional constraints make the right course impossible to pursue. OBJECTIVE. The purpose of this study was to assess the frequency and severity with which radiologists experience moral distress and to explore moral distress's root causes and countermeasures. METHODS. This study entailed a national survey that evaluated moral distress in radiology. The survey incorporated the validated Moral Distress Scale for Health Care Professionals, along with additional questions. After the scale was modified for applicability to radiology, respondents were asked to assess 16 clinical scenarios in terms of frequency and severity of moral distress. On May 10, 2022, the survey was sent by e-mail to 425 members of radiology practices included on a national radiology society's quality-and-safety LISTSERV. The Measure of Moral Distress for Health Care Professionals (MMD-HP) score was calculated for each respondent as a summary measure of distress across scenarios (maximum possible score, 256). RESULTS. After 12 surveys with incomplete data were excluded, the final analysis included 93 of 425 respondents (22%). A total of 91 of 93 respondents (98%) experienced at least some moral distress for at least one scenario. A total of 17 of 93 respondents (18%) had left a clinical position due to moral distress; 26 of 93 (28%) had considered leaving a clinical position due to moral distress but did not leave. The mean MMD-HP score was 73 ± 51 (SD) for those who had left, 89 ± 47 for those who had considered leaving but did not leave, and 39 ± 35 for those who had never considered leaving (p < .001). A total of 41 of 85 respondents (48%) thought that the COVID-19 pandemic had influenced their moral distress level. Across respondents, the three scenarios with highest moral distress were related to systemic causes (higher case volume than could be read safely, high case volume preventing teaching residents, and lack of administrative action or support). The countermeasure most commonly selected to alleviate moral distress was educating leadership about sources of moral distress (71%). CONCLUSION. Moral distress is prevalent in radiology, typically relates to systemic causes, and is a reported contributor to radiologists changing jobs. CLINICAL IMPACT. Urgent action by radiology practice leadership is required to address moral distress, as radiologists commonly practice in environments contradictory to their core values as physicians.

How the on-going conflict in Ukraine is impacting cardiovascular health.

Following the outbreak of war in Ukraine on 24 February 2022, we are witnessing a conflict that has led to many civilian, military, and volunteer civil defence force casualties. Those civilians living in a theatre of war are directly exposed to combat-attributable trauma and risks from explosive ordnance. The United Nations Office for the High Commissioner for Human Rights (UNHCR) reported that by 4th September, there had been 13 917 confirmed casualties in the non-combatant civilian population with 5718 deaths1; these figures are likely to be significant underestimates. It is believed that ∼18 million people have been directly impacted by the hostilities with more than 8 million internally displaced. Given the widespread destruction of housing and civil infrastructure, including the disconnection of basic utilities, initial activity to aid those affected has focused on ensuring safe shelter with humanitarian support in the form of clean water, nutrition, sanitation, and clothing. Medical services have been badly disrupted. Monitored by the World Health Organization Surveillance System for Attacks on Health Care, as of 6th September, there had been 512 attacks against healthcare facilities, personnel, patients, transportation, and supply depots, with 100 people killed and 129 injured.2 Some of the remaining clinical resources, particularly those in central Ukraine, have been repurposed as trauma centres to receive casualties from the battlefront if staff are available. These professionals inevitably face ethical treatment dilemmas concerning the allocation of increasingly scarce medicines and equipment, a possible source of moral distress. This war is being pursued against the backdrop of the continuing COVID-19 pandemic, with interruption of public health initiatives to immunize a population already vulnerable due to poor vaccine uptake. Barriers arising from the conflict have hampered the treatment of those infected with coronavirus or other communicable diseases such as HIV and tuberculosis—co-infection with the latter two pathogens is relatively common in Ukraine. The conditions endured by people sheltering from the fighting or seeking refuge through humanitarian corridors, if accessible, seem likely to increase the risk of contagion.

The responsibility to care: lessons learned from emergency department workers' perspectives during the first wave of the COVID-19 pandemic in Canada.

BackgroundThis study’s objective was to examine emergency department (ED) workers’ perspectives during the Canadian COVID-19 first wave.MethodsThis qualitative study included workers from nine Canadian EDs who participated in 3 monthly video focus groups between April and July 2020 to explore (1) personal/professional experiences, (2) patient care and ED work, (3) relationships with teams, institutions and governing bodies. Framework analysis informed data collection and analysis.ResultsThirty-six focus groups and 15 interviews were conducted with 53 participants (including 24 physicians, 16 nurses). Median age was 37.5 years, 51% were female, 79% had more than 5 years’ experience. Three main themes emerged. (1) Early in this pandemic, participants felt a responsibility to provide care to patients and solidarity toward their ED colleagues and team, while balancing many risks with their personal protection. (2) ED teams wanted to be engaged in decision-making, based on the best available scientific knowledge. Institutional decisions and clinical guidelines needed to be adapted to the specificity of each ED environment. (3) Working during the pandemic created new sources of moral distress and fatigue, including difficult clinical practices, distance with patients and families, frequent changes in information and added sources of fatigue. Although participants quickly adapted to a “new normal”, they were concerned about long-term burnout. Participants who experienced high numbers of patient deaths felt especially unprepared.InterpretationED workers believe they have a responsibility to provide care through a pandemic. Trust in leadership is supported by managers who are present and responsive, transparent in their communication, and involve ED staff in the development and practice of policies and procedures. Such practices will help protect from burnout and ensure the workforce’s long-term sustainability.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-022-00306-z.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States

PhenomenonMoral distress, which occurs when someone’s moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians’ distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents. ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children’s hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized. FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents’ strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed. InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Whom are we seeking to protect? Extremely preterm babies and moral distress

Advances in perinatal care bring with them ethical challenges and difficult questions. When should we provide life-sustaining interventions, and who should decide? Particularly at the edges of viability, some clinicians may feel required to provide a level of care that they believe is not in the patient's interests, resulting in moral distress.This article will discuss the complex nature of moral distress arising during the care of extremely preterm babies. It will describe the challenges and cognitive biases present when contemplating potential harms to the baby and recognize the possible costs to both healthcare provider and baby when moral distress arises. Both clinicians caring for extremely preterm babies and the families themselves can experience moral distress. This article argues that for clinicians, recognizing the range of possible sources of moral distress is vital in order to appropriately address moral distress. Moral distress may arise from a desire to protect the baby, but also from an impulse to protect oneself from the emotional burdens of care. Addressing moral distress requires reflection on the factual beliefs, experiences and personal values which lie behind the distress, both within oneself and in discussion with colleagues. Moral distress indicates that a situation is ethically challenging, but it does not necessarily mean that a wrong decision has been made.

Clinical Pearls

Moral distress occurs when an individual faces constraints in doing the right thing, which challenges the ability to preserve integrity and can result in adverse outcomes such as burnout, diminished well-being, and poor quality patient care. During a pandemic, these constraints can be greatly increased, with health care staff experiencing greater moral distress.Thomas and colleagues conducted a survey with staff in a pediatric intensive care unit, including physicians/advanced practice providers, registered nurses, and respiratory therapists, to explore the extent and sources of moral distress during the COVID-19 pandemic. They found Although more research is needed, the authors suggest that moral resilience can be cultivated by organizations providing support and strategies to promote a healthy work environment.See Article, pp e80–e98Having a family member in the intensive care unit (ICU) can be a very stressful experience and can lead to the development of post–intensive care syndrome in families. Cognitive behavioral therapy (CBT) has been used to treat patients’ psychological distress both in-person and with mobile health apps. However, it is unknown if a CBT mobile app would be effective with family members.Petrinec and colleagues examined the feasibility of using a mobile app to deliver CBT to family members of adult ICU patients. They found Although a larger, randomized controlled trial is needed, the findings support the feasibility of using a mobile health app for family members of ICU patients.See Article, pp 451–458Microaspiration is the leaking of oral or gastric secretions into the lower airway that often occurs in patients receiving mechanical ventilation. Such leakage can result in ventilator-related complications such as ventilator-associated pneumonia. Pepsin A found in tracheal secretions is a biomarker of microaspiration of gastric secretions.Talbert and colleagues examined the association between pepsin A found in tracheal secretions and clinical outcomes in adult patients in the intensive care unit (ICU) who were expected to receive ventilation for at least 36 hours. They found Prevention bundles such as elevating the head of the bed 30º, management of endotracheal tube cuff pressure, and oropharyngeal suctioning were standard care during this study. Further research is needed to better understand the factors that affect microaspiration and ventilator-related events.See Article, pp 443–450Workplace turbulence is known to contribute to burnout and turnover in critical care nurses. Research shows that healthy work environments (HWEs) improve both nurse and patient outcomes. The American Association of Critical-Care Nurses (AACN) developed an HWE framework with 6 evidence-based standards to improve work settings—skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.Pena and colleagues implemented interventions using the AACN framework and evaluated the effect on nurse satisfaction and retention 2 years later. They found The findings reinforce the value of using an evidence-based framework to implement and evaluate strategies to improve workplace environments. The authors recommend further development of sustainable interventions to improve staff stability.See Article, pp 426–433

Moral distress among school leaders: an Alberta, Canada study with global implications

ABSTRACT Moral distress is experienced when one knows the right thing to do, but cannot do it because of institutional or external constraints. This study aimed to understand the extent to which moral distress affects a school leader’s role, and the key sources of moral distress. Using a web-based survey (n = 954) and focus groups including school leaders, we found that the increasing complexity of classrooms places competing demands upon school leaders. Moral distress emerged from expectations from school district leaders and parents. This study introduces moral distress to educational research, and provides a conceptual lens for describing the moral dimension of challenges that school leaders face. Future scholarship is necessary to understand the impact of moral distress on school leaders as they strive to adapt to increasing demands from both their districts and their school communities.

Moral Distress of Nursing Professionals of a Psychosocial Care Center.

Moral Distress (MD) is experienced by individuals from the contradiction existing between their actions and convictions. This study aimed to analyze the moral distress experienced by nursing professionals working at the CAPS and to describe and identify the feelings resulting from MD and coping mechanisms. This is a qualitative research that adopted the Bardin Content Analysis method. Seven Nursing professionals of both CAPS shifts participated in the research. Four categories emerged from the thematic analysis of the statements of these professionals, as follows: Environment as a source of moral distress; Shortage of funding and improvisations; Feelings that emerged from the experiences of Moral Distress and Coping Mechanisms of professionals. In this study, we observed that Macapá's Gentileza CAPS professionals experience MD in their daily life, associated with structural environment issues and insufficient (human and material) resources that resulted in feelings of helplessness, discouragement, demotivation, and struggle. This MD allowed these professionals to build coping mechanisms against moral distress, such as dialogue and sharing anguish with the team.

Phronesis of nurses: A response to moral distress.

As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. To describe and analyze the phronesis applied by nurses in the face of moral distress. The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses' phronesis. Twenty-seven nurses from Taiwan. The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse's emotional movement. Action and idea transformation are collectively called phronesis in this study. Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Compensating for Conflicting Policy Goals: Dilemmas of Teachers’ Work With Asylum-Seeking Pupils in Sweden

ABSTRACTThis article examines challenges experienced by teachers of asylum-seeking pupils in Sweden, where the right to education is part of a policy of promoting “normal life” during the asylum process. A theoretical framework contributed a deepened understanding of the teachers’ experiences as street-level bureaucrats. Interviews indicated that institutional factors, lack of training, and insufficient support within the educational system constrained the teachers’ work. They developed strategies for dealing with the dilemma of being impeded in providing education equivalent to that of resident pupils but still struggled with how the asylum process affected classroom work. They were sidelined by a lack of control over the asylum decision, processed outside school. This was a source of moral distress and an additional workload, as catering to asylum-seekers’ needs was left to their discretion. Conflicting goals of educational and immigration policy thus conditioned their work and risked undermining the compensatory pedagogical task.

What Should Physicians Do When They Disagree, Clinically and Ethically, with a Surrogate's Wishes?

When patients' surrogates and physicians disagree about the appropriateness of aggressive treatment in intensive care units (ICUs), physicians can experience surrogates' demands as sources of moral distress. This article addresses the virtues and communication strategies needed to respond appropriately in such situations. Specifically, we offer a framework and language that rely on moral community to facilitate common ground and alleviate moral distress.

Moral distress of nursing undergraduates: Myth or reality?

During their education process, nursing undergraduates experience ethical conflicts and dilemmas that can lead to moral distress. Moral distress can deprive the undergraduates of their working potential and may cause physical and mental health problems. We investigated the experiences of the undergraduates in order to identify the existence of moral distress caused by ethical conflict and dilemmas experienced during their nursing education. Ethical considerations: This study was designed according to the principles of research with human beings and was approved by the Human Research Ethics Committee. A qualitative multiple-case study. Two federal higher education institutions were surveyed, from which 58 undergraduates in nursing participated in the study. The undergraduates were undergoing their professional training. The data were collected through focus groups and were submitted to thematic content analysis, with the resources of the ATLAS TI 7.0 software. Moral distress in undergraduates is a reality and was identified in three axes of analysis: (1) moral distress is experienced by undergraduates in the reality of healthcare services, (2) the teacher as a source of moral distress, and (3) moral distress as a positive experience. The undergraduates in nursing manifest moral distress in different stages of their education, particularly during their professional training. The academic community should reflect and seek solutions for the reality of moral distress in undergraduates.

Understanding and Addressing Moral Distress

Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action. Research on moral distress among nurses has identified that the sources of moral distress are many and varied and that the experience of moral distress leads some nurses to leave their jobs, or the profession altogether. This article considers both moral distress and moral residue, a consequence of unresolved moral distress. First, we will explain the phenomenon of moral distress by providing an historical overview, identifying common sources, and describing strategies for recognizing moral distress. Next we will address moral residue and the crescendo effect associated with moral residue. We will conclude by considering ways to address moral distress and the benefits of a moral distress consult service.