Conceptualising moral resilience for nursing practice

The term ‘moral resilience’ has been gaining momentum in the nursing ethics literature. This may be due to it representing a potential response to moral problems such as moral distress. Moral resilience has been conceptualised as a factor that inhibits immoral actions, as a favourable outcome and as an ability to bounce back after a morally distressing situation. In this article, the philosophical analysis of moral resilience is developed by challenging these conceptualisations and highlighting the risks of such limiting perspectives. It is argued that moral resilience is best understood as a virtue with two associated vices, faintheartedness and rigidity. The intellectual virtue of practical wisdom is required to express resilience as a virtue. This understanding leads to recommendations for professional education, for practice and for further research.     

Development and psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer

Aim. To report the development and psychometric testing of the Moral Distress Thermometer. The Moral Distress Thermometer is a new screening tool to measure moral distress in nurses who practise in the hospital setting. Background. Moral distress occurs when one knows the ethically correct thing to do, but is prevented from acting on that perceived obligation. It is a well documented phenomenon with negative consequences that may be experienced by nurses. Creating an instrument to effectively and efficiently measure moral distress in a timely way has been identified as a priority for nursing. Design. This study used a cross‐sectional survey design. Methods. Data collection for this research occurred in 2009. Participants simultaneously completed either the adult or pediatric version of the Moral Distress Scale version 2009 and the Moral Distress Thermometer. A total of 529 participants from various clinical areas completed both tools. Results. Coefficients alpha were adequate for both Adult (0·90) and Pediatric (0·92) Moral Distress Scale 2009 scales. Statistically significant Pearson correlations were found for the Moral Distress Thermometer with Adult Moral Distress Scale 2009 and Pediatric Moral Distress Scale 2009 and higher Moral Distress Thermometer, Adult Moral Distress Scale 2009 and Pediatric Moral Distress Scale 2009 means for participants who had left or who considered leaving a position because of moral distress. Conclusion. These findings provide support for the validity of the Moral Distress Thermometer.     

Nurse Practitioners’ Experiences of Moral Distress in the Continuing Care Setting

This article describes a qualitative study designed to understand nurse practitioners’ (NPs) experiences with moral distress in the continuing care setting. The findings confirm that NPs in this setting experience moral distress. These experiences are in response to tensions that arise when factors interfere with their ability to provide “good” patient care. Five themes emerged as important factors: patients, perceptions, physicians, palliation, and policies. Moral distress is a substantial issue for NPs in the continuing care setting. Further research is required to examine NP’s experience with moral distress in other settings and identify solutions to resolve and respond to this distress.     

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

Many studies have examined clinical and institutional moral problems in the practice of nurses that have led to the experience of moral distress. The causes and implications of moral distress in nurses, however, have not been understood in terms of their implications from the perspective of virtue ethics. This paper analyzes how nurses reach for the telos of their practice, within a context of moral distress. A qualitative case study was carried out in a private hospital in Brazil. Observation and semi‐semistructured interviews were conducted with 13 nurse participants. With the aid of ATLAS.ti software, the data were analyzed by using thematic content analysis using virtue ethics to theorize the findings. These nurses experienced a loss of their nursing identity as they encountered an ambiguous telos and the domination of institutional values. In their reach for the telos of their practice, nurses found an environment permeated by ethical challenges, which not only created moral distress but also created professional invisibility, a phenomenon referred to as ‘invisibility of the self’.     

Moral distress in carers for people with an intellectual disability who died during the COVID-19 pandemic,a template analysis extending the Barlem and Ramos model of moral distress

Background

This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic.

Method

Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews.

Results

Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for.

Conclusions

This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.     

Moral distress, advocacy and burnout: Theorising the relationships

Burnout is a major contributor to shortages of experienced nurses. The research literature shows a correlation between moral distress and burnout in critical care nurses. This paper reports on part of an interpretive interactionist study concerning nurses' experiences of moral distress which prompted attempts to advocate for vulnerable patients. One critical incident is used as an example of the qualitative findings of the study. In this paper, we theorise about what happened when nurses advocated for their patients by challenging medical treatments which the nurses believed to be both inappropriate and to contributing to patient suffering. When attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger. Being an unsuccessful advocate resulted in nurses being relocated within the hospital, nurses being scapegoated and/or burning out. The theoretical links which this paper makes between advocacy, moral distress and burnout are supported by empirical data from the study.     

Perils of proximity: a spatiotemporal analysis of moral distress and moral ambiguity

The physical nearness, or proximity, inherent in the nurse-patient relationship has been central in the discipline as definitive of the nature of nursing and its moral ideals. Clearly, this nearness is in service to those in need of care. This proximity, however, is not unproblematic because it contributes to two of the most prolonged difficulties, both for individual nurses and the discipline of nursing--moral distress and moral ambiguity. In this paper we explore proximity using both a moral and geographical lens and offer some insights regarding this practice reality. We examine the effect of proximity to patients on nurses' moral responsiveness, particularly as it affects nurses' moral distress. Proximity is paradoxical in this regard because, while it propels nurses to act, it can also propel nurses to ignore or abandon. Likewise, we argue that nursing's tendency to define itself in relation to the closeness of the nurse-patient relationship leads to problems of moral ambiguity. Our recommendations include moving others closer to the bedside and thus to the work of nursing in the literal and theoretical sense.     

Identification of risk factors for moral distress in nurses: basis for the development of a new assessment tool

This article proposes to identify risk factors for moral distress from the literature, validate them through expert analysis and provide the basis for a new tool to assess the risk of moral distress among nurses. Moral distress is related to the psychological, emotional and physiological aspects of nursing. It arises from constraints caused by various circumstances and can lead to significant negative consequences. A scoping review and validation through expert analysis were used. The research question guiding this study was as follows: What is known about risk factors for moral distress in nursing? The research was conducted using multiple sources including electronic databases and lists of references from relevant literature. The final sample consisted of 38 studies. A validation analysis was conducted by experts during December 2014 and June 2015. To exclude a risk factor item, at least 80% of the experts had to agree with the exclusion. In total, 53 risk factors for moral distress were identified, reviewed by the experts and grouped to form a new instrument that may help to identify risk for moral distress and to address its consequences.     

Moral distress experienced by care leaders’ in older adult care: A qualitative study

Background

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.

Aim

The purpose of the study was to examine care leaders’ experiences of moral distress in their daily work in older adult care.

Methodology

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.

Findings

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.

Conclusion

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.     

Unable to answer the call of our patients: mental health nurses' experience of moral distress

When health practitioners' moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non-professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses' possible responses to intolerable situations.     

Development and evaluation of a moral distress scale

AIM OF THE STUDY: This methodological research developed and evaluated the moral distress scale from 1994 to 1997. BACKGROUND/RATIONALE: Although nurses confront moral questions in their practice daily, few instruments are available to measure moral concepts. The methodological design used a convenience sample consisted of 214 nurses from several Unites States hospitals. The framework guiding the development of the moral distress scale (MDS) included Jameton's conceptualization of moral distress, House and Rizzo's role conflict theory, and Rokeach's value theory. Items for the MDS were developed from research on the moral problems that nurses confront in hospital practice. The MDS consists of 32 items in a 7-point Likert format; a higher score reflects a higher level of normal distress. RESULTS: Mean scores on each item ranged from 3.9 to 5.5, indicating moderately high levels of moral distress. The item with the highest mean score (M=5.47) was working where the number of staff is so low that care is inadequate. Factor analysis yielded three factors: individual responsibility, not in the patient's best interest, and deception. No demographic or professional variables were related to moral distress. Fifteen percent of the nurses had resigned a position in the past because of moral distress. CONCLUSION: The results support the reliability and validity of the MDS.     

Ethical practice in nursing: working the in-betweens

BACKGROUND: While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. PURPOSE: With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. DESIGN AND METHODS: Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. FINDINGS: The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. CONCLUSIONS: Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.     

Nurses' moral agency in negotiating parental participation in care

The purpose of this study was to investigate the issues for nurses in facilitating parental participation in the care of the hospitalized child. A qualitative study informed by grounded theory was undertaken. Nine nurses were recruited from an acute, high-dependency, 23-bed paediatric cardiac/renal unit in Melbourne, Australia. Data collection involved individual semistructured interviews, hospital policies related to family-centred care and a focus group interview. Constant comparative analysis was undertaken to develop an understanding of the data collected in the context of the nurses' experiences and the environment in which they work. Moral agency was identified as the central phenomenon of the study. Causal conditions related to this included the child's best interests, disputes about care and nurses' expectations. These causal conditions were seen to potentially lead to moral distress for the nurses. The coping mechanisms and strategies that affected moral agency have been identified.     

Moral distress questionnaire for clinical nurses: instrument development

Title.  Moral distress questionnaire for clinical nurses: instrument development.
Aim.  This paper is a report of a study to develop and test the psychometric properties of a culture-sensitive moral distress questionnaire among nurses employed in a variety of work settings.
Background.  In the course of the last decade, there has been increased interest in capturing healthcare professionals' experiences of stress associated with ethical dilemmas. Ethical issues emerge in grey areas and are often blurred, and have thus received insufficient attention.
Method.  The study comprised two phases: a qualitative phase to elicit the culture-specific themes and a quantitative phase, comprising the design of a 15-item questionnaire. The questionnaire was then completed by a convenience sample of 179 nurses from a variety of work settings. The data were collected in 2006.
Results.  Factor analysis resulted in three factors representing moral distress: (1) problems caused by work relationships among staff; (2) problems due to lack of resources; and (3) problems caused by time pressure. With regard to the construct validity of the questionnaire, differences between community and hospital nurses were tested, and a statistically significant difference was found between them in two among the three factors (relationships and time). The stability of the measures was examined by test-retest reliability and revealed statistically significant results.
Conclusions.  The instrument exhibits acceptable reliability and validity in the Israeli cultural context. Further research is needed to evaluate the measure in other cultural settings.     

Ethical Dilemma and Moral Distress: Proposed New NANDA Diagnoses

PURPOSE: To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. SOURCES USED: Journal articles, books, and focus group research findings. DATA SYNTHESIS: Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. CONCLUSION: The two proposed NANDA diagnoses fill a void in current standardized terminology. PRACTICE IMPLICATIONS: It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.     

Moral distress in nurse leaders—A scoping review of the literature

Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles—2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures—the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.