Moral injury in healthcare professionals: A scoping review and discussion.

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

Analysis of graduating nursing students' moral courage in six European countries.

BACKGROUND: Moral courage is defined as courage to act according to one's own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses' career. AIM: To analyse graduating nursing students' moral courage and the factors associated with it in six European countries. RESEARCH DESIGN: A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with a single question (visual analogue scale 0-100), the questionnaire also covered several background variables. PARTICIPANTS AND RESEARCH CONTEXT: The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students' moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires. ETHICAL CONSIDERATIONS: Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent. RESULTS: The mean of graduating nursing students' self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0-100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students' moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves. DISCUSSION AND CONCLUSIONS: In all countries, the graduating nursing students' moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research.

Nursing, advocacy and public policy.

This article draws attention to the nature and importance of public policy. It argues that if nurses are to influence the quality of healthcare effectively, they must be engaged with policymakers to get nursing care issues on the policy agenda. There is an ethical imperative to do so, driven by the advocacy role of the nurse and rooted in the values base of nursing. In addition, it is argued that if one takes the role of patient advocacy seriously, as core to the nursing role, two things are required of nurses: We must (a) broaden the conceptualisation of patient advocacy beyond the individual patient to the system of healthcare resourcing and provision and (b) see systemic change as important as change at the bedside.

Unmet care needs of older people: A scoping review.

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

Niven and Scott (2003): Sixteen years of hindsight.

This paper revisits a 2003 publication in Nursing Philosophy: The need for accurate perception and informed judgement in determining the appropriate use of the nursing resource: hearing the patient's voice. The author suggests that the basic ideas and focus of this 16-year-old paper are still topical and relevant in considerations of nursing care. However, it is also suggested that greater attention to the importance of the nurse-patient relationship in considerations of resource allocation, and potential rationing of nursing care, would have strengthened the original paper.

Resource allocation and rationing in nursing care: A discussion paper.

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.

Ethical elements in priority setting in nursing care: A scoping review.

BACKGROUND: Nurses are often responsible for the care of many patients at the same time and have to prioritise their daily nursing care activities. Prioritising the different assessed care needs and managing consequential conflicting expectations, challenges nurses' professional and moral values. OBJECTIVE: To explore and illustrate the key aspects of the ethical elements of the prioritisation of nursing care and its consequences for nurses. DESIGN, DATA SOURCES AND METHODS: A scoping review was used to analyse existing empirical research on the topics of priority setting, prioritisation and rationing in nursing care, including the related ethical issues. The selection of material was conducted in three stages: research identification using two data bases, CINAHL and MEDLINE. Out of 2024 citations 25 empirical research articles were analysed using inductive content analysis. RESULTS: Nurses prioritised patient care or participated in the decision-making at the bedside and at unit, organisational and at societal levels. Bedside priority setting, the main concern of nurses, focused on patients' daily care needs, prioritising work by essential tasks and participating in priority setting for patients' access to care. Unit level priority setting focused on processes and decisions about bed allocation and fairness. Nurses participated in organisational and societal level priority setting through discussion about the priorities. Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient's situation, age, and the perceived good that treatment and care brings to patients. The negative consequences of priority setting activity were nurses' moral distress, missed care, which impacts on both patient outcomes and nursing professional practice and quality of care compromise. CONCLUSIONS: Analysis of the ethical elements, the causes, concerns and consequences of priority setting, need to be studied further to reveal the underlying causes of priority setting for nursing staff. Prioritising has been reported to be difficult for nurses. Therefore there is a need to study the elements and processes involved in order to determine what type of education and support nurses require to assist them in priority setting.

Unsupervised self-testing as part public health screening for HIV in resource-poor environments: some ethical considerations.

The use of unsupervised self-testing as part of a national screening program for HIV infection in resource-poor environments with high HIV prevalence may have a number of attractive aspects, such as increasing access to services for hard to reach and isolated populations. However, the presence of such technologies is at a relatively early stage in terms of use and impact in the field. In this paper, a principle-based approach, that recognizes the fundamentally utilitarian nature of public health combined with a focus on autonomy, is used as a lens to explore some of the ethical issues raised by HIV self-testing. The conclusion reached in this review is that at this point in time, on the basis of the principles of utility and respect for autonomy, it is not ethically appropriate to incorporate unsupervised HIV self-testing as part of a public health screening program in resource-poor environments.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

BACKGROUND: Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. METHODS: For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. FINDINGS: An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients. INTERPRETATION: Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths. FUNDING: European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

What is nursing in the 21st century and what does the 21st century health system require of nursing?

It is frequently claimed that nursing is vital to the safe, humane provision of health care and health service to our populations. It is also recognized however, that nursing is a costly health care resource that must be used effectively and efficiently. There is a growing recognition, from within the nursing profession, health care policy makers and society, of the need to analyse the contribution of nursing to health care and its costs. This becomes increasingly pertinent and urgent in a situation, such as that existing in Ireland, where the current financial crisis has lead to public sector employment moratoria, staff cuts and staffing deficits, combined with increased patient expectation, escalating health care costs, and a health care system restructuring and reform agenda. Such factors, increasingly common internationally, make the identification and effective use of the nursing contribution to health care an issue of international importance. This paper seeks to explore the nature of nursing and the function of the nurse within a 21st century health care system, with a focus on the Irish context. However, this analysis fits into and is relevant to the international context and discussion regarding the nursing workforce. This paper uses recent empirical studies exploring the domains of activity and focus of nursing, together with nurses perceptions of their role and work environment, in order to connect those findings with core conceptual questions about the nature and function of nursing.

The impact of the work environment of nurses on patient safety outcomes: a multi-level modelling approach.

BACKGROUND: Patient safety is a priority for health services in all countries. The importance of the nurse's role in patient safety has been established. Effective nurse staffing levels, nurse education levels, and a positive work environment for nurses are factors which are known to impact on patient safety outcomes. OBJECTIVES: This study sought to explore the relationship between the ward environment in which nurses practice and specific patient safety outcomes, using ward level variables as well as nurse level variables. The outcomes were nurse-reported patient safety levels in the wards in which they work, and numbers of formal adverse events reports submitted by nurses in the last year. DESIGN: This cross-sectional quantitative study was carried out within a European FP7 project: Nurse Forecasting: Human Resources Planning in Nursing (RN4CAST) project. SETTINGS: 108 general medical and surgical wards in 30 hospitals throughout Ireland. PARTICIPANTS: All nurses in direct patient care in the study wards were invited to participate. Data from 1397 of these nurses were used in this analysis. METHODS: A nurse survey was carried out using a questionnaire incorporating the Practice Environment Scale of the Nursing Work Index (PES-NWI). Ethical approval was obtained from the authors' institution and all ethics committees representing the 30 study hospitals. Multilevel modelling was carried out to examine the impact of ward level factors on patient safety. These included proportions of nurses on the ward educated to degree level, and aggregated ward-level mean for PES-NWI scores. RESULTS: The study results support other research findings indicating that a positive practice environment enhances patient safety outcomes. Specifically at ward level, factors such as the ward practice environment and the proportion of nurses with degrees were found to significantly impact safety outcomes. The models developed for this study predicted 76% and 51% of the between-ward variance of these outcomes. The results can be used to enhance patient safety within hospitals by demonstrating factors at ward-level which enable nurses to effectively carry out this aspect of their role. CONCLUSIONS: The importance of ward-level nurse factors such as nurse education level and the work environment should be recognised and manipulated as important influences on patient safety.

A risk to himself: attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical-surgical units.

Psychiatric patients are liable to stereotyping by healthcare providers. We explored attitudes toward caring for psychiatric patients among 13 nurses working in general hospitals in Ireland. Participants thought aloud in response to a simulated patient case and described a critical incident of a patient for whom they had cared. Two attitudinal orientations were identified that correspond to stereotypical depictions of risk and vulnerability. The nurses described psychosocial care strategies that were pragmatic rather than authentically person-centered, with particular associations between risk-oriented attitudes and directive nursing care. Nurses had expectations likely to impede relationship building and collaborative care. Implications arising include the need for improved knowledge about psychiatric conditions and for access to professional development in targeted therapeutic communication skills.

Patient autonomy and choice in healthcare: self-testing devices as a case in point.

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility.

Diagnostic self-testing: autonomous choices and relational responsibilities.

Diagnostic self-testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point-of-care facilities and at home. Designed to allow earlier detection of diseases, self-testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve health and reduce health costs. However, the full implications of future home-based diagnostic technology for individuals and society remain unclear due to their novelty. We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home-based self-testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation. While the ethical issues are not necessarily new, the development of home-based self-testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities.

Communicating with nurses: patients' views on effective support while on haemodialysis.

BACKGROUND: Haemodialysis therapy is one form of treatment for end-stage renal disease (ESRD). Patients have to adhere to a strict regimen of dialysis, dietary and fluid restrictions, and medications. AIM: This study explores the experiences of 16 people with ESRD undergoing hospital-based haemodialysis therapy. METHOD: A small-scale study using a phenomenological method was carried out. A total of 16 patients were interviewed and qualitative interpretive analysis was used. RESULTS: The theme 'communicating with nurses: reality versus myth' was created from the analysis of the interview data. Participants indicated that nurses rarely communicated with them during dialysis. The only time nurses seemed to approach participants was to manage the physical and technical aspects of care. CONCLUSION: This study will hopefully increase nurses' awareness of the importance of effective communication in providing supportive care to patients with renal disease.

The development and psychometric evaluation of the Perceptions of Empowerment in Midwifery Scale.

OBJECTIVE: to develop and psychometrically evaluate a scale to measure midwives' perceptions of their levels of empowerment. DESIGN: a cross-sectional postal survey, carried out in May 2005. PARTICIPANTS: a random sample of midwives practising in Ireland (n=244). MEASUREMENT AND FINDINGS: the Perceptions of Empowerment in Midwifery Scale (PEMS) was developed and psychometrically evaluated in this study. Exploratory factor analysis was performed on the scale, using Principal Axis Factoring with an oblique (Direct Oblimin) rotation. This suggested three sub-scales: autonomous practice; effective management and women-centred practice. The scale was found to be a valid and reliable instrument. KEY CONCLUSIONS: the PEMS is an appropriate tool to measure midwives' perceptions of their levels of empowerment. IMPLICATIONS FOR PRACTICE: within the current context of change in Irish midwifery, this research facilitates the articulation and measurement of the conditions that facilitate empowerment in midwifery, which can assist in enhancing the midwifery contribution to maternity care.

Perspectives on midwifery power: an exploration of the findings of the inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda, Ireland.

The Lourdes Hospital Inquiry: An inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda, Ireland, of 2006 recounts in detail the circumstances within which 188 peripartum hysterectomies were carried out at the hospital between 1974 and 1998. The findings of the inquiry have serious ramifications for Irish healthcare delivery and have implications for many professional groups, including midwives. The findings prompt clear questions about the relative position or power of midwives within maternity care. These questions are examined in this article, through the analysis and application of various theoretical perspectives on power. Critical views of power focus on the socio-political nature of oppressive structures within society and seek mechanisms to address these. Stemming from structure versus agency debates, Giddens's structuration theory examines the agency-structure interaction and stresses the centrality of agents' roles in the social reproduction of structures. Postmodernism, particularly drawing on the work of Michel Foucault, focuses on a fluid conception of power while also describing the nature of disciplinary power. It offers midwives a way of viewing power as productive and dispersed. Drawing on different aspects of these perspectives on power, helps us to understand midwives' relative positions and power relations and how to enhance these to prevent future tragic outcomes such as those reported in the inquiry report.

Lost in translation, or the true text: mental health nursing representations of psychology.

One theme of academic discourse and research in mental health nursing is the exploration and application of psychosocial models of nursing practice. Despite this, the influence of disciplinary psychological knowledge on practitioners' talk about nursing practice has not been extensively researched. To address this gap, the authors analyzed talk about psychological work using transcripts of 10 focus groups involving 59 mental health nurses. Nurses identified a psychological domain of practice as central to their work. Given the amount of time spent with clients, nurses are the prime resource for psychological work. Psychological talk was organized into three categories related to the nursing process and organizational context and analyzed through empowerment and critical perspectives on power. Although technical ("formal") and everyday ("informal") discourses were generally well integrated, the authors question the oral basis to this body of knowledge in terms of accountability to service users and as a marker of disempowerment.

Irish nurses' and midwives' understanding and experiences of empowerment.

AIM: This study explored conceptualizations of empowerment among Irish nurses and midwives. BACKGROUND: Current literature on the meaning of empowerment lacks consensus. As a result there is a likelihood that empowerment will be conceptualized differently between managers and subordinates. METHOD: In order to get a sense of how Irish practitioners viewed empowerment, 10 focus groups were held in locations throughout Ireland (n = 93). A national distribution of participants was obtained. RESULTS: Twenty-one different responses emerged representing what nurses and midwives understood by the term empowerment. In relation to experiences of empowerment, six themes were found to impact on empowerment experiences. Three themes emerged as central to empowerment. One theme (education for practice) was identified as an antecedent to empowerment. CONCLUSION: Empowerment is a complex concept and its meaning is contextually determined. Managers play a key role in impacting on the empowerment perceptions of Irish nurses and midwives.