Unveiling nurses' end-of-life care experiences: Moral distress and impacts.

PC-FACS

Evidence-Based Review and Discussion Points

A correlational embedded mixed method design was used for this study. A purposive sample of 205 critical care nurses (CCNs) provided quantitative data for the study. A focus group interview of five CCNs provided the qualitative data. The Moral Distress Scale (MDS), Professional Quality of Life Scale (ProQOL), and Medication Administration Error (MAE) Scale and demographics form were used to measure quantitative data. Quantitative findings included the majority of participants were female (91.7%); mean age 47 (SD = 7.91) years; mean years worked as a nurse was 23 (SD = 8.48); mean years worked on respective unit was 13.6 (SD = 8.45) and mean numbers of hours worked per week was 37 (SD = 8.45). Nineteen CCNs (9.5%) indicated they were considering leaving their current work position based on moral distress. Statistically significant positive relationships between moral distress, compassion fatigue, and perceived mediation error were found. Simultaneous multiple regression was conducted to determine the accuracy of the IVs; moral distress and compassion fatigue in predicting medication scores while controlling for gender, age, work status, marital status, resignation based on moral distress and others. Regression results indicate the overall model significantly predicted the Medication Administration Error Subscale of Nursing Staffing, R2 = .11; the subscale Disagree with Definition R2 = .13, and the subscale Fear, R 2 = .13. A summary of regression coefficients indicates only one (moral distress) of the 10 variables significantly contributed to the models predicting Medication Administration Error Subscale of Nursing Staffing, and Fear. For the Disagree with Definition subscale moral distress, compassion fatigue, and work status were the only variables that significantly contributed to the models. Focus group interview data revealed several themes including Process or Practice Issues, Staff Experience and Support, Negative Emotions and Other Nurses were identified as key in understanding medication error. Nurses did not relate moral distress or compassion fatigue to medication errors directly. This study contributed to the understanding of nurses' perceptions of medication error, moral distress, and compassion fatigue. Furthermore, an enhanced understanding of critical care nurses insight regarding medication error and power relations within the critical care environment was gained.

Background Critical care nurses care for many adults at end of life and it is known that these nurses can experience moral distress. Moral distress occurs when nurses are unable to perform what they believe is ethically correct. There has been speculation that psychological empowerment may ameliorate moral distress among critical care nurses. However, research has yet to examine the relationship between moral distress and psychological empowerment in the population of critical care nurses. Objectives To describe the relationships between moral distress, psychological empowerment and select demographics in critical care nurses caring for patients at EOL. Method Using a quantitative correlational survey design a sample of critical care nurses (n=277) was recruited using the American Association of Critical Care Nurses online Newsletter. Instruments included the Moral Distress Scale (MDS) for Intensity and Frequency each having the subscales of a) not in patient's best interest, b) individual responsibility, and c) deception and the Psychological Empowerment Instrument (PEI) with subscales of a) meaning, b) competence, c) self-determination, and d) impact. Results MDS intensity mean score was high (m=5.34, SD=1.32) and positively correlated with age (r=.179, p=.011) and ELNEC critical care training (r=.185, p=.008). MDS frequency mean score was moderate (m=2.51, SD=0.87) and correlated with nurse collaboration in EOL patient care conferences (r=-.191, p=.007), with nurses reporting more collaboration experiencing moral distress less frequently. PEI scores (m=5.31, SD=1.00) were high and positively correlated with age (r =.139, p=.031), years of critical care experience (r=.165, p=.010), collaboration in EOLC conferences (r=.163, p=.012), EOLC education in the past year (r=.221, p=.001). Total PEI scores negatively correlated with moral distress frequency scores (r=-.194; p=.010). Multiple regression analysis indicated that for every 1-point increase on the PEI, moral distress frequency scores decreased by 0.222 points (p=<.01). Conclusion This study contributes to the understanding of the relationship between moral distress and psychological empowerment in critical care nurses caring for patients in end of life. The significant negative correlation between psychological empowerment and moral distress frequency in this population of nurses is of particular interest and can serve as the first step in testing interventions to decrease moral distress.

Influence of spirituality on moral distress and resilience in critical care staff: A scoping review

Although many nursing studies have focused on moral distress, very few have looked at moral distress and emergency nurses despite the fact that this group works in stressful, fast-paced environments that often involve situations that can lead to moral distress. The goals of this qualitative study are to determine how emergency nurses define moral distress, describe the experiences of moral distress by emergency nurses and its impact, and identify possible strategies to combat moral distress. This study used a phenomenological qualitative design. A convenience sample was used and included 8 registered nurses from 3 different emergency departments in a midsized urban county in the South Central United States. A structured open-ended interview technique was used. Four major themes were identified: (1) there was no face of the family, (2) asking God for forgiveness, (3) flipping the switch, and (4) it changes who we are. Nurses in this study all reported experiencing moral distress. Sources of moral distress identified included patient advocacy issues, professional behavior of other health care professionals, internal conflicts with what they perceived to be the right thing to do and that which was asked of them, and guilt over their own feelings about patient care. These nurses described effective and ineffective coping mechanisms.

Many healthcare professionals have left their professions recently because of increased moral distress, and the COVID-19 pandemic has had a further major impact on the ever-changing healthcare environment. The purpose of the study was to examine care leaders' experiences of moral distress in their daily work in older adult care. A qualitative design was used. The data consisted of texts from interviews with care leaders (N = 8) in an older adult care context. Content analysis was used to analyse the data. Five themes emerged: (1) moral distress arises from a lack of time, (2) moral distress contributes to a sense of inadequacy but also a sense of responsibility, (3) moral distress arises from an imbalance in values, (4) increased knowledge and open discussion help reduce moral distress and (5) reflection, increased support and increased resources can reduce moral distress. Moral distress is something that care leaders, according to this study, experience daily in an older adult care context and it is considered to have increased. Care leaders can experience moral distress from a lack of time; patient-related, relative-related or other ethically difficult situations or an imbalance between own values and an organisation's, other caregivers', patients' and/or patients' relatives values. Increased staffing resources, more knowledge (training and lectures) and time for reflection individually, in groups or with an outside expert could increase care leaders' insights into and ability to reduce moral distress. Although situations that are characterised by moral distress are burdensome, care leaders have the opportunity to learn from such situations through reflection and discussion and can develop strategies for future ethical challenges. Future research could focus on exploring caregivers' experiences of moral distress.

BackgroundThe hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation.MethodsThe present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis.ResultsThree themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists’ caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint.ConclusionsIn general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study.

Moral distress, a complex and multidimensional phenomenon, remains insufficiently addressed in clinical practice, arising when professionals perceive threats to their moral integrity. This quantitative, cross-sectional, correlational study examined how personal, interpersonal, and organizational factors contribute to moral distress among healthcare professionals. Eighty healthcare workers (primarily nurses and physicians) at a single hospital completed validated scales measuring organizational dehumanization, interprofessional team coordination, and empathy components (personal distress and perspective-taking), as well as different types of morally distress triggering events (system, patient, team-patient, and team-member). Results showed that organizational dehumanization, where employees feel treated as mere tools, was the strongest predictor of moral distress. Interprofessional team coordination mitigated moral distress, especially in patient care and team interactions. Perspective-taking was associated with overall moral distress and with distress related to team-patient and patient care events, while personal distress influenced system-related distress but not overall moral distress. These findings highlight that reducing organizational dehumanization and improving team coordination are key strategies to prevent moral distress and support ethical practice among healthcare professionals.

Moral distress in critical care nursing has been well studied; however, there is a gap in the literature related to moral distress among nurses and nursing students practicing in the community. This paper describes moral distress experienced during participation in the Interprofessional Care Access Network, a community-based nurse-led education and practice program providing longitudinal care coordination for underserved individuals and families in rural communities and urban neighborhoods. Two case studies represent client situations resulting in moral distress for nursing faculty and students. Contributing factors include unaddressed social determinants creating barriers to health and health care; inexperience and discomfort with people living in extreme poverty; lack of access to critical services for the most vulnerable; and powerlessness to influence discriminatory systems. Strategies are described to reduce moral distress and build moral resilience among students and faculty practicing in the community. Research is needed to expand understanding of causes, interventions, and consequences of moral distress in public health nursing.

<h3>Context:</h3> While health-care workers (HCW) spend their working hours caring for others, many are challenged to find the time and energy for self-care and suffer because of it. <h3>Objective:</h3> To examine facilitators and barriers facing organizations to a) support health-care workers psychological self-care and b) protect them from moral distress. <h3>Study Design and Analysis:</h3> Key informants were identified through scholarly and grey literature reviews and snowball recruitment. Potential informants were invited to participate in a one-hour, semi-structured interview. Interviews were audio recorded, transcribed verbatim and analyzed using a thematic approach in NVivo 12. <h3>Setting:</h3> Interviews were conducted between November 2021 and February 2022 with HCW from multiple disciplines and health-care sectors across Canada. <h3>Population Studied:</h3> Anyone who self-identified as working in the health-care field, including front line workers and administrators. <h3>Instrument:</h3> An interview guide was developed for this study informed by the literature review. <h3>Outcome Measures:</h3> Facilitators and barriers to a) supporting psychological self-care and, b) protection from moral distress at the individual, team, and organizational levels. <h3>Results:</h3> A total of 29 interviews were completed with 30 participants. Facilitators to supporting psychological self-care included prioritizing self-care and utilization of available resources, positive peer relationships, and supportive leadership, policies, and guidelines. Barriers included hesitancy among HCW to identify themselves as feeling burnt out, an existing unsupportive culture as well as management who were unable to relate to their workers. HCW identified several facilitators to protection from moral distress, including a feeling that their work was making a difference, open communication within teams, and supportive resources such as a wellness team. In contrast, some HCW felt that moral distress was not well understood, and that an unhealthy culture of overwork coupled with a lack of resources were key barriers to protection. <h3>Conclusions:</h3> In this exploration of psychological health and safety in health-care workplaces across Canada we uncovered a multitude of opportunities for improvement. Participants not only spoke of their challenges to supporting psychological self-care and being able to protect themselves from moral distress but offered many suggestions that organizational leaders can implement in the short-term and longer-term.

Moral distress is a far-reaching problem for nurses in different settings as it threatens their health. This study examined which situations lead to moral distress in home-care nursing, how and with which consequences home-care nurses experience moral distress, and how they cope with morally stressful situations and the resulting moral distress. A qualitative interview study with reflexive thematic analysis was used. We conducted semi-structured interviews with 20 home-care nurses in Germany. The study was approved by the Data Protection Office and Ethics Committee of the German Federal Institute for Occupational Safety and Health. Twenty (14 female and 6 male) home-care nurses were interviewed between April and August 2023 at their chosen location. The situations leading to moral distress were inadequate care of the person in need of care, not being able to protect one's health, extended responsibility for the entire care arrangement, work-privacy conflicts, and conflicts between the understanding of care or professional ethics and the performance and billing system. The nurses experienced moral distress as they worked alone and provided care in the patient's territory. Short- and long-term strains with destructive cognitions, negative emotions, physical symptoms, and health consequences were reported. They faced challenges in coping with moral distress on institutional and individual levels. In cases of tension between the service and billing system and the understanding of these nurses' care services, moral distress is unavoidable. Alternative forms of organization and billing modalities, such as payment by time and the expansion and refinancing of service, should be implemented. The latter relates to systematic case and ethics meetings. Further, a transfer of medical activities, such as the prescription of wound material to registered nurses, could prevent morally stressful situations and improve patients' quality of care.

Physicians often experience moral distress from being prevented from taking what they believe to be the right course of action. Although causes and consequences of moral distress have been studied, little research offers insight into the significance of feeling morally challenged, especially in medicine. This study was undertaken to advance understanding of what physicians experience when encountering morally challenging situations and to examine how those experiences influence their interactions with the world of health care. Guided by hermeneutic phenomenology, the authors conducted semistructured interviews with purposefully sampled Canadian physicians from September 2022 to January 2023. Analysis used Van Manen's 6 activities of hermeneutic research and included "story crafting" to sharpen insights. Late in that process, Van Manen's "lived existentials" was determined to provide a strong framework for physicians' experiences of moral distress. Of the 12 physicians interviewed, all experienced varied and long-lasting emotional reactions to morally challenging experiences. The emotions associated with moral distress, reported as inevitable, were experienced in ways that aligned with the lived existentials of body, space, time, and relations. A richer understanding of physicians' lived experiences with moral distress can help mentors and educators more thoughtfully engage in conversations about it with colleagues and learners. This study highlights the core dimensions of moral distress through body, space, time, and relations, thereby providing a means to enrich discussion about emotions and their transformational power. Through such nuanced consideration, calls for emotional candor may be strengthened to enhance practice by acknowledging the scope of impact that efforts to deliver care are likely to provoke.

Exploring moral distress in Australian midwifery practice