Re-examining the relationship between moral distress and moral agency in nursing.

In recent years, the phenomenon of moral distress has been critically examined-and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re-examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re-centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of 'narrow' moral distress and the value of re-considering moral distress.  Finally, we provide an action-oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency.

Nurturing moral community: A novel moral distress peer support navigator tool.

Moral distress is a pervasive phenomenon in healthcare for which there is no straightforward "solution." Rhetoric surrounding moral distress has shifted over time, with some scholars arguing that moral distress needs to be remedied, resolved, and eradicated, while others recognize that moral distress can have some positive value. The authors of this paper recognize that moral distress has value in its function as a warning sign, signaling the presence of an ethical issue related to patient care that requires deeper exploration, rather than evidencing identification of the "right" course of action. Once the experience of moral distress is identified, steps ought to be taken to clarify the moral issue, and, if possible and reasonable, the patient's values ought to be prioritized. This paper offers concrete actions steps, drawn from theory, which can be used in clinical practice to provide peer support or to facilitate self-reflection for morally distressed individuals. This approach empowers morally distressed individuals to explore ethical issues, identify concrete steps that can be taken, and mitigate feelings of powerlessness that are often associated with moral-constraint distress. The questions guide individuals and peers to reflect first on the micro-space and then more broadly on the institutional culture, facilitating meso- and macro-reflection and action.

Operationalizing the role of the nurse ethicist: More than a job.

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, nursing practice has much to contribute to the ethical practice of healthcare, and with the strong grounding in ethics and aspiration for social justice considerations in nursing, there is no wonder that the specific role of the nurse ethicist has emerged. Nurse ethicists, expert in nursing practice and the application of ethical theories and concepts, are well positioned to guide nurses through complex ethical challenges. However, there is limited discussion within the field regarding the specific job responsibilities that the nurse ethicist ought to have. The recent appearance of job postings with the title "nurse ethicist" suggest that some healthcare institutions have identified the value of a nurse in the practice of ethics and are actively recruiting. Discomfort about the possibility of others defining the role of the nurse ethicist inspired this paper (and special issue). If the nurse ethicist is to be seen as an integral part of addressing ethical dilemmas and ethical conflicts that arise in healthcare, then nurse ethicists ought to be at the forefront of defining this role. In this paper, we draw upon our own experiences as nurse ethicists in large academic healthcare systems to describe the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a clinical setting linked to academic programs. Drawing upon our experience and the literature, we describe how we perceive the nurse ethicist adds value to healthcare organizations and teams of professional ethicists.

A divided community: A descriptive qualitative study of the impact of the COVID-19 pandemic on nurses and their relationships.

AIMS: To identify the personal and professional impact of the COVID-19 pandemic on clinical nurses with regard to personal and workplace safety, personal and professional relationships and perceptions of their team, organization and community, and to understand lessons learned to inform future responses to pandemics or global emergencies. DESIGN: Qualitative, descriptive free-text surveys, informed by appreciative inquiry. METHODS: Nurses working in adult COVID- and non-COVID cohort medical-surgical and intensive care units, outpatient cancer and general surgery centres were invited to participate. Data were collected between April and October 2021 and analysed using summative content analysis. RESULTS: In total, 77 participants completed free-text surveys. Five themes were identified: (1) Constraints on nursing: barriers in communication and diminished patient safety and quality of care; (2) Navigating uncertainty: the emotional toll of the pandemic; (3) Team solidarity, renewed appreciation and reaffirming purpose in nursing work; (4) Enhanced trust versus feeling expendable; and (5) Increased isolation and polarization within communities. Nurses described a perceived negative impact on a number of their relationships, including with patients, employer and community. They described a huge emotional toll that included feelings of isolation and polarization. While some nurses described feeling supported by their team and employer, others described feeling expendable. CONCLUSION: Nurses' responses provided insights into negative emotional experiences during the pandemic due to heightened uncertainty and fear, and also the importance of support received from peers, colleagues and their employer. Nurses experienced feelings of isolation and polarization within their communities. The varied responses reflect the importance of societal solidarity when faced with global emergencies, and the need for nurses to feel valued by their patients and employer. IMPACT: Effective responses to public health emergencies require individuals and communities to work together to achieve collective goals. Efforts to retain nurses are critical during global emergencies. PATIENT OR PUBLIC CONTRIBUTION: No patient and public involvement.

Sub-categories of moral distress among nurses: A descriptive longitudinal study.

BACKGROUND: There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard "narrow" definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown. RESEARCH AIMS: To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument. RESEARCH DESIGN: A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6 weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data. PARTICIPANTS: Registered nurses from four hospitals within one large healthcare system in Midwest United States. ETHICAL CONSIDERATIONS: IRB approval was obtained. RESULTS: 246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by "other" distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation. CONCLUSIONS: Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.

The Ethics Resource Caregiver Program: Equipping Nurses as Ethics Champions.

AbstractBackground: Nurses face ethical issues and experience moral distress in their everyday work. A nursing ethics champion program was developed at a hospital in the United States. METHODS: As part of a quality improvement project, pre- and post-training surveys were developed to assess whether the program was feasible and sustainable, enhanced nurse confidence in recognizing and addressing ethical issues and moral distress, and increased nurse knowledge of institutional resources for addressing the same. Qualitative and quantitative analyses were performed. RESULTS: Thirteen nurses from both the critical care and medical/surgical settings participated in the program. The program proved feasible. Attrition after the educational sessions raised concerns about sustainability. Survey results suggest an association between participating in the program's educational sessions and increased nurse confidence in recognizing and addressing ethical issues and moral distress, as well as identifying institutional resources that can assist nurses with the same. DISCUSSION: Opportunities for future nursing ethics champion programs include increasing the interactivity and duration of educational sessions, making programs multidisciplinary, and creating materials for nurses to more easily share with colleagues. It would be valuable for future research to measure the impact of nursing ethics champion programs on nursing turnover. IMPLICATIONS: A nursing ethics champion program has the potential to help nurses feel better equipped to navigate ethical issues and moral distress in their everyday work.

Ethical challenges faced by nurses during the COVID-19 pandemic: a scoping review protocol.

OBJECTIVE: The aim of this scoping review is to describe the literature reporting on ethical challenges faced by nurses during the COVID-19 pandemic, including the contextual characteristics of ethical challenges, and the strategies to address these challenges. INTRODUCTION: The COVID-19 pandemic presented many ethical challenges to nurses, ranging from allocating scarce resources, to balancing a duty of care with self-preservation, and implementing visitation restrictions. Internationally, there has been a range of reported issues, but few studies have described strategies to overcome these challenges. INCLUSION CRITERIA: Studies that report on ethical challenges faced by nurses while caring for patients during the COVID-19 pandemic will be included. Studies that report on strategies to address these challenges will also be considered for inclusion. METHODS: This scoping review will be conducted in accordance with the methods outlined by JBI and reported using PRISMA-ScR guidance. The following databases will be searched for eligible studies from November 2019 to present day: PubMed, CINAHL, Ovid, PsycINFO, the Cochrane Library, and Scopus. No language restrictions will be applied. Studies will be reviewed for inclusion by 2 independent reviewers and a data extraction form developed specifically for this review will be used to extract data relevant to the review questions. Results will be analyzed and presented according to the concepts of interest, using tables, figures, images, and supporting narrative synthesis.

Reflective Debriefs as a Response to Moral Distress: Two Case Study Examples.

Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases ("Moral Distress Reflective Debriefs"). We discuss how the debriefing literature and other clinical ethics activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress.

RESPONDER: A qualitative study of ethical issues faced by critical care nurses during the COVID-19 pandemic.

AIMS: To identify and understand ethical challenges arising during COVID-19 in intensive care and nurses' perceptions of how they made "good" decisions and provided "good" care when faced with ethical challenges and use of moral resilience. BACKGROUND: Little is known about the ethical challenges that nurses faced during the COVID-19 pandemic and ways they responded. DESIGN: Qualitative, descriptive free-text surveys and semi-structured interviews, underpinned by appreciative inquiry. METHODS: Nurses working in intensive care in one academic quaternary care centre and three community hospitals in Midwest United States were invited to participate. In total, 49 participants completed free-text surveys, and seven participants completed interviews. Data were analysed using content analysis. RESULTS: Five themes captured ethical challenges: implementation of the visitation policy; patients dying alone; surrogate decision-making; diminished safety and quality of care; and imbalance and injustice between professionals. Four themes captured nurses' responses: personal strength and values, problem-solving, teamwork and peer support and resources. CONCLUSIONS: Ethical challenges were not novel but were amplified due to repeated occurrence and duration. Some nurses' demonstrated capacities for moral resilience, but none described drawing on all four capacities. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers would benefit from greater ethics training to support their nursing teams.

Evaluating Decision-Making Capacity: When a False Belief about Ventilators Is the Reason for Refusal of Life-Sustaining Treatment.

In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.

The moral distress model: An empirically informed guide for moral distress interventions.

AIMS AND OBJECTIVES: To explore moral distress empirically and conceptually, to understand the factors that mitigate and exacerbate moral distress and construct a model that represents how moral distress relates to its constituent parts and related concepts. BACKGROUND: There is ongoing debate about how to understand and respond to moral distress in nursing practice. DESIGN: The overarching design was feminist empirical bioethics in which feminist interpretive phenomenology provided the tools for data collection and analysis, reported following the COREQ guidelines. Using reflexive balancing, the empirical data were combined with feminist theory to produce normative recommendations about how to respond to moral distress. The Moral Distress Model presented in this paper is a culmination of the empirical data and theory. METHODS: Using feminist interpretive phenomenology, critical care nurses in the United Kingdom (n = 21) were interviewed and data analysed. Reflexive Balancing was used to integrate the data with feminist theory to provide normative recommendations about how to understand moral distress. RESULTS: There are five compounding factors that exacerbate/ mitigate nurses' experiences of moral distress: epistemic injustice; the roster lottery; conflict between one's professional and personal responsibilities; ability to advocate and team dynamics. In addition to the causal connection and responses to moral distress, these factors make up the moral distress model which can guide approaches to mitigate moral distress. CONCLUSIONS: The Moral Distress Model is the culmination of these data and theorising formulated into a construct to explain how each element interacts. We propose that this model can be used to inform the design of interventions to address moral distress.

Clinician and Ethicist Perspectives: Understanding Moral Distress in Gender-Affirming Care for Pediatric Patients.

Using case examples and other common scenarios, the authors outline several types of moral distress that clinicians may experience when providing pediatric gender-affirming care. The authors also offer strategies for managing moral distress and issue a call to action for professional organizations to enhance support for gender-affirming clinicians.