Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study.

Background: Nurses in adult care settings frequently encounter moral distress due to the daily ethical obligations they must fulfill. In contrast to other healthcare professionals, nurses often grapple with a heightened frequency of moral dilemmas, resulting in increased moral distress. Objective: This study aimed to explore the levels and relationship between moral caring competency and moral distress among Ghanaian nurses in adult care settings. Methods: This quantitative study utilized a descriptive-correlational design. A multistage sampling was used to select three public hospitals. Simple random sampling was used to recruit 231 nurses from the three public hospitals. Data were collected from June to July 2023 using validated questionnaires. The study utilized frequency and percentages, mean and standard deviation, and Spearman's Correlation. Results: The nurses had a low level of moral caring competency (M = 2.18, SD = 0.340). The composite moral distress score was 227.31, indicating a high level of moral distress among the nurses. Furthermore, there was a moderate, negative significant relationship between moral caring competency and moral distress (rs = -.474, N = 231, p <0.001). Conclusions: Nurses in public hospitals had limited personal cognitive, affective, and psychomotor abilities to address patient moral issues. The nurses also experience significant moral distress when delivering patient care. Furthermore, to decrease the level of moral distress, moral caring competency should be strengthened among nurses. Therefore, it is recommended that nurse administrators provide adequate organizational support and implement continuous moral training to improve nurses' moral caring competency and mitigate their moral distress. Healthcare policymakers are encouraged to develop or refine policies to navigate moral dilemmas and reduce moral distress among nurses. Future studies employing qualitative designs can explore the influence of culture on moral caring competency within the Ghanaian setting.

Does moral distress in emergency department nurses contribute to intentions to leave their post, specialisation, or profession: A systematic review.

Background: There is a global shortfall of nurses. Despite national targets to increase nurse training and retention, the numbers leaving the profession continue to rise. Emergency departments (EDs) consistently record above average staff-turnover. Meanwhile descriptions of moral distress amongst emergency nurses are increasing. It is vital to consider the long-term emotional and psychological impact of moral distress on the emergency nursing workforce. However, the events which trigger moral distress in the emergency department may differ from those described in other clinical areas. A clearer understanding of the effects of moral distress on intention to leave could help identify those at risk and inform decisions on interventions designed to mitigate moral distress, aiding nurse retention and the organisational stability of health services. Aim: This systematic review aims to synthesise the available evidence on the association between moral distress and intention to leave in emergency nurses. Methods: A systematic search of studies was performed on MEDLINE, CINAHL, PsychINFO, Web of Science and Cochrane databases (8th -10th June 2022). Results were screened and quality-assessed with cross-checks. The heterogeneity of samples and insufficient data precluded statistical pooling and meta-analysis. Consequently, narrative synthesis was performed. Results: Five studies reported quantitative results eligible for synthesis. Low to moderate levels of moral distress were reported in emergency nurses; contrasting starkly with the significant proportion who reported having left or considered leaving due to moral distress (up to 51%). Sparse, mostly low-quality evidence was identified, highlighting a need for more robust research. Current tools for measuring moral distress appear not to capture the unique pressures which contribute to moral distress in emergency nurses. Conclusions: Emergency nurses cite moral distress as a reason for leaving. Further study is required to determine the levels of moral distress associated with intentions to leave and the strength of that association. This is fundamental to the design of effective retention policies. Future research should also explore the applicability of current moral distress measures to the emergency department, with consideration given to developing emergency department specific tools. PROSPERO Registration number: CRD42022336241 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=336241.

Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study.

BACKGROUND: Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited. OBJECTIVE: This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level. METHODS: This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants' experiences. RESULTS: The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing. CONCLUSIONS: It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel. TRIAL REGISTRATION: ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54180.

Moral Injury Post-COVID-19: More Than Military? A Theological Perspective.

Against the background of growing discussions on medical moral injury, I outline sharp divergences between military and medical moral injury. These are often ignored or minimalised, to the detriment of establishing a sharper conceptualization of medical moral injury. A theological exploration finds a common thread between the two, and frames moral injury as the shattering of individual's moral expectations, which in turn triggers the shattering of the person's morality framework that formed them.

Strategic technological processes in hospitals: Conflicts and personal experiences of healthcare teams.

BACKGROUND: Global health systems operate amid dynamic factors, including demographic shifts, economic variations, political changes, technological progress, and societal trends that lead to VUCA reality (Volatility, Uncertainty, Complexity, and Ambiguity). To address these challenges, healthcare organizations are increasingly turning to Strategic Technological Processes and digital transformation. RESEARCH OBJECTIVE: Against this background, the current study examined the personal experiences, conflicts, difficulties, and moral dilemmas attendant upon accommodating this digital transformation of healthcare professionals. PARTICIPANTS: The study involved 27 healthcare professionals working in Israeli hospitals, whose experiences and perspectives were central to understanding the impact of digital transformation in healthcare settings. RESEARCH DESIGN: The study methodology rested on in-depth interviews, which were analyzed through the prism of the Listening Guide analytical technique. ETHICAL CONSIDERATIONS: The research obtained pre-approval from the Ethics Committee at the researcher's institution. FINDINGS: The study revealed that the healthcare professionals are indeed facing ethical conflicts and personal challenges related to digitalization (such as providing the best quality of care, being the best caregiver, and acting for the betterment of the hospital). It also identified dilemmas resulting from conflicts between the needs and demands of the health system and the healthcare professionals' values and resources. DISCUSSION: The study findings highlight the impact of ethical and moral challenges accompanying strategic organizational and digital transformation changes implemented by healthcare organizations worldwide. These challenges arise as healthcare institutions adapt to the demands of the 21st century, potentially leading to burnout and moral distress among healthcare professionals, further exacerbating the already stressful reality they face. CONCLUSION: In conclusion, the study emphasizes the critical necessity for comprehensive support strategies to alleviate stress and burnout among healthcare professionals. As healthcare organizations and personnel navigate significant organizational changes to address contemporary challenges, prioritizing the well-being of healthcare workers through effective support mechanisms becomes imperative.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland.

PURPOSE: Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH: This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS: The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE: Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Management dilemmas in pediatric nephrology: moving from friction to flourishing in "challenging" cases.

BACKGROUND: The circumstances surrounding chronic kidney disease and its impact on families can be complex and difficult to navigate, leading to these cases being labeled "challenging." CASE PRESENTATION: We present the case of an adolescent with kidney failure due to unremitting systemic illness and multiple complications ultimately resulting in the family's request to forgo dialysis. Medical team members wrestled with meeting the family's needs among internal and external constraints. CONCLUSION: Past experiences, systemic inequities, differing perspectives, and consequential decision-making within individual belief systems can lead to friction between and among medical team members and families. As pediatric nephrologists, we must shift our focus from the "challenging" patient or family to addressing what is challenging their ability to flourishing.

Implementation of the Dementia Isolation Toolkit in long-term care improves awareness but does not reduce moral distress amongst healthcare providers.

BACKGROUND: Healthcare providers may experience moral distress when they are unable to take the ethically or morally appropriate action due to real or perceived constraints in delivering care, and this psychological stressor can negatively impact their mental health, leading to burnout and compassion fatigue. This study describes healthcare providers experiences of moral distress working in long-term care settings during the COVID-19 pandemic and measures self-reported levels of moral distress pre- and post-implementation of the Dementia Isolation Toolkit (DIT), a person-centred care intervention designed for use by healthcare providers to alleviate moral distress. METHODS: Subjective levels of moral distress amongst providers (e.g., managerial, administrative, and front-line employees) working in three long-term care homes was measured pre- and post-implementation of the DIT using the Moral Distress in Dementia Care Survey and semi-structured interviews. Interviews explored participants' experiences of moral distress in the workplace and the perceived impact of the intervention on moral distress. RESULTS: A total of 23 providers between the three long-term care homes participated. Following implementation of the DIT, subjective levels of moral distress measured by the survey did not change. When interviewed, participants reported frequent experiences of moral distress from implementing public health directives, staff shortages, and professional burnout that remained unchanged following implementation. However, in the post-implementation interviews, participants who used the DIT reported improved self-awareness of moral distress and reductions in the experience of moral distress. Participants related this to feeling that the quality of resident care was improved by integrating principals of person-centered care and information gathered from the DIT. CONCLUSIONS: This study highlights the prevalence and exacerbation of moral distress amongst providers during the pandemic and the myriad of systemic factors that contribute to experiences of moral distress in long-term care settings. We report divergent findings with no quantitative improvement in moral distress post-intervention, but evidence from interviews that the DIT may ease some sources of moral distress and improve the perceived quality of care delivered. This study demonstrates that an intervention to support person-centred isolation care in this setting had limited impact on overall moral distress during the COVID-19 pandemic.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review.

Background: Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. Aim: To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines. Data sources: First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. Results: We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Conclusions: Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being. Future work: Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. Limitations: The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample. Study registration: This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

The National Health Service needs healthy, motivated staff to provide high-quality patient care. Nurses, midwives and paramedics experience poor psychological health (e.g. stress/anxiety) because of pressured environments and the difficulties of healthcare work. This study planned to better understand the causes of poor psychological ill-health in nurses, midwives and paramedics and find which interventions might help and why. We analysed the literature using a method called 'realist review' to understand how interventions work (or not), why, and for who. We tested our findings with patients, the public, nurses, midwives and paramedics in our stakeholder group. We reviewed over 200 papers/reports and identified five main findings: (1) existing solutions (interventions) are disjointed, focus mainly on the individual (not the system) and do not recognise enduring stressors enough; (2) when there is a blame culture it is difficult to encourage staff psychological well-being; (3) the needs of the system often override staff psychological well-being at work; (4) upholding and implementing personal and professional values at work can have negative personal costs; and (5) it is difficult to design, identify and implement solutions that work well for staff groups in different circumstances with varied causes of poor psychological health. Healthcare organisations should consider: (1) changing (rebalancing) the working environment to help healthcare professionals rest, recover and thrive; (2) investing in multiple-level system (not just individual) approaches to staff psychological well-being; (3) continuing to reduce stigma; (4) ensuring the essential needs of staff are prioritised (rest-breaks/hydration/hot food) as building blocks for other solutions; (5) addressing the blame culture, assuming staff are doing their best in difficult conditions; (6) prioritising staff needs, as well as patient needs. We will provide guidance and recommendations to policy-makers and organisational leaders to improve work cultures that tackle psychological ill-health and suggest new areas for research.

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

BACKGROUND: Nurses providing care to patients with end-of-life or terminal illnesses often encounter ethically challenging situations leading to moral distress. However, existing quantitative studies have examined moral distress using instruments that address general clinical situations rather than those specific to end-of-life care. Furthermore, qualitative studies have often been limited to participants from a single unit or those experiencing moral distress-induced circumstances. A comprehensive and integrated understanding of the overarching process of moral distress is vital to discern the unique circumstances surrounding end-of-life care and its consequential impacts. RESEARCH OBJECTIVES: To explore the moral distress experiences of nurses who are frequently involved in caring for patients with end-of-life or terminal illnesses and apply it to two existing theories: the model of moral distress and the ecological model. RESEARCH DESIGN: A qualitative descriptive approach was employed. PARTICIPANTS AND RESEARCH CONTEXT: Seven focus group interviews involving 30 nurses were performed. The subsequent transcriptions underwent rigorous content analysis. ETHICAL CONSIDERATIONS: We obtained Institutional Review Board approval from a university. Focus group interviews were conducted with nurses who agreed to participate and signed the consent form. FINDINGS: The moral distress-inducing factors and nurses' perceived impact of moral distress were identified and categorized based on moral distress theories and ecological models. A total of 15 categories and 30 subcategories across the following 4 domains were derived: (1) intrapersonal, (2) interpersonal, (3) organizational, and (4) structural factors. CONCLUSIONS: End-of-life-specific circumstances induced moral distress among nurses, with both negative and positive impacts identified. Effective organizational and policy support is essential to manage conflicts, form a healthy organizational culture, provide training, and prevent unnecessary expenses due to the negative consequences of moral distress.

Coping strategies of intensive care unit nurses reducing moral distress: A content analysis study.

BACKGROUND: Moral distress has negative effects on physical and mental health. However, there is little information about nurses' coping strategies reducing moral distress. AIM: The purpose of this study was to investigate the coping strategies of intensive care unit nurses reducing moral distress in Iran. STUDY DESIGN: This is a qualitative study with a content analysis approach. PARTICIPANTS AND RESEARCH CONTEXT: The research sample consisted of nurses working in intensive care units of teaching hospitals affiliated to Tehran University of Medical Sciences. Samples were selected among eligible nurses by purposive sampling. Data were obtained through 17 in-depth, individual, and semi-structured interviews with 17 nurses. Graneheim and Lundman's (2004) 6-step content analysis method was used to analyze the data. Data management was also performed by MAXQDA software version 20. The COREQ checklist was used to report the study. ETHICAL CONSIDERATIONS: This project was approved by the Ethics Committee of Tehran University of Medical Sciences. All ethical guidelines in research were followed. FINDING: The data analysis resulted in the formation of two main categories of desirable coping strategies (with two subcategories of compensation and rejuvenation) and less desirable coping strategies (with three subclasses of indifference over time, escape and concealment). DISCUSSION: The intensive care unit nurses in dealing with ethical problems first try to solve the problem through discussion, but when they fail to resolve it peacefully, they resort to several coping strategies. Factors, such as increasing experience, lack of support from hospital managers and officials, poor communication between colleagues, the need to maintain hierarchy, fear of reprimand, and a sense of powerlessness, changed the nurses' preferred strategies. It is important for managers to provide a blame/punishment-free atmosphere for expression of ethical experiences; a supportive atmosphere in which staff can engage in ethical discussions without fear of punishment. They should also provide opportunities for rest, rejuvenation, and adequate training for their employees.

Measuring moral distress in health professionals using the MMD-HP-SPA scale.

BACKGROUND: Moral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes. METHODS: A regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice. RESULTS: The mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9). CONCLUSIONS: Female, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey.

INTRODUCTION: By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support. METHODS: A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making. RESULTS: 305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility. CONCLUSION: Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Understanding psychological outcomes following exposure to potentially morally injurious events in animal care: development of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals.

AIMS: To generate a taxonomy of potentially morally injurious events (PMIE) encountered in veterinary care and develop an instrument to measure moral distress and posttraumatic growth following exposure to PMIE in the veterinary population. METHODS: Development and preliminary evaluation of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals (MD-PTG-VP) employed data from veterinary professionals (veterinarians, veterinary nurses, veterinary technicians) from Australia and New Zealand across three phases: (1) item generation, (2) content validation, and (3) construct validation. In Phase 1 respondents (n = 46) were asked whether they had experienced any of six PMIE and to identify any PMIE not listed that they had experienced. In Phase 2 a different group of respondents (n = 11) assessed a list of 10 PMIE for relevance, clarity and appropriateness. In Phase 3 the final instrument was tested with a third group of respondents (n = 104) who also completed the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a measure of posttraumatic stress, and the Stress-Related Growth Scale-Short Form (SRGS-SF) a measure of perceived posttraumatic growth. Spearman's correlation coefficients were calculated between respondent scores on each of the MD-PTG-VP subscales, the SPRINT, and the SRGS-SF to assess construct validity. RESULTS: A 10-item taxonomy of PMIE encountered in veterinary care was generated in Phase 1. Items were deemed relevant, clear and appropriate by veterinary professionals in Phase 2. These were included in the developed instrument which measures frequency and impact of exposure to 10 PMIE, yielding three subscale scores (exposure frequency, moral distress, and posttraumatic growth). Assessment of construct validity by measuring correlation with SPRINT and SRGS-SF indicated satisfactory validity. CONCLUSIONS: The MD-PTG-VP provides an informative tool that can be employed to examine professionals' mental health and wellbeing following exposure to PMIE frequently encountered in animal care. Further evaluation is required to ascertain population norms and confirm score cut-offs that reflect clinical presentation. CLINICAL RELEVANCE: Once fully validated this instrument may be useful to quantify the frequency and intensity of positive and negative aspects of PMIE exposure on veterinary professionals so that accurate population comparisons can be made and changes measured over time.

"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes.

BACKGROUND: A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?" METHODS: A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway. RESULTS: Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes. CONCLUSIONS: Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

The moral distress and resilience among emergency nurses in Arar city: Saudi Arabia.

BACKGROUND: Understanding moral distress and resilience is crucial for supporting the well-being of emergency nursing staff and improving patient care. However, there is limited research specifically examining moral distress and resilience among emergency nursing staff in ARAR city hospitals. AIMS: This study aims to examine moral distress and resilience levels among emergency nursing staff in ARAR city hospitals. Specifically, the study seeks to determine the correlation between moral distress and resilience among emergency nursing staff and examine differences in the levels of moral distress and resilience among different demographic and occupational characteristics. METHODS: A cross-sectional study design was employed, involving a non-probability stratified sample of emergency nursing staff from two hospitals in ARAR city. The participants completed a Brazilian Moral Distress Scale in Nurses (MDSN-BR) and Rushton Moral Resilience Scale in Nurses (RMRS). Statistical analyses, including descriptive statistics and one-way- ANOVA, were conducted to analyze the data. RESULTS: The study found that emergency nursing had a moderate level of moral distress, with a mean frequency of 2.70 (SD = 1.02) and a mean intensity of 2.79 (SD = 1.04). The overall self-reported moral resilience was also moderate, with a mean score of 2.48 (SD = 0.77). Significant positive correlations were observed between resilience and both moral distress frequency (r = 0.48, p = 0.001) and intensity (r = 0.48, p = 0.001). Educational levels and nursing positions were associated with variations in moral distress and resilience. Postgraduate diploma emergency nursing reported the highest levels of moral distress frequency (3.12, SD = 1.14) and intensity (3.21, SD = 1.16). A bachelor's degree in nursing exhibited higher levels of personal integrity (3.06, SD = 0.87), while a master's degree in nursing showed higher levels of moral efficacy (2.88, SD = 1.09). Head nurses experienced higher levels of moral distress compared to other positions (3.08, SD = 1.37 for frequency; 3.18, SD = 1.29 for intensity). CONCLUSION: The study revealed that emergency nursing experienced relatively moderate levels of moral distress, which could be attributed to insufficient multidisciplinary teams and unprepared actions. The findings also highlighted moderate levels of moral resilience, particularly in relational integrity. Educational levels and nursing positions were found to influence moral distress and resilience. These results underscore the need for targeted interventions to support the well-being of emergency nurses and enhance ethical decision-making.

Moral distress among acute mental health nurses: A systematic review.

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

Inductive process of moral distress development in viewpoints from surgical nurses: a mixed-method study.

BACKGROUND: Moral distress is a multifactorial and complex phenomenon influenced by various individual, cultural, and systemic factors. This study aimed to investigate the frequency and intensity of nurses' moral distress, explore their experiences, and develop the conceptual model of risk factors of moral distress in surgical units and operating rooms. METHOD: This is a sequential mixed-method study conducted at four teaching hospitals affiliated with the Qom University of Medical Sciences. In the first step, the moral distress of nurses in surgical units and operating rooms was investigated by a survey. The participants included nurses who worked in the operating room and surgical units. (n = 180). The data was collected by a Moral Distress Scale-Revised (MDS-R) questionnaire. In the second step, the experiences of nurses regarding risk factors of moral distress were explored using semi-structured interviews and analyzed using the conventional content analysis by Graneheim and Lundman's approach. RESULTS: One hundred eighty nurses participated in this study. The mean total moral distress scores ranged from 12 to 221, with a mean (SD) of 116.8 (42.73). The causes of moral distress cited with the highest frequency and intensity related to the 'role of healthcare providers'. The experiences of the participants in the theme 'Inductive process of moral distress development' were categorized into three categories: 'Melting into the faulty system', 'Power and the system as distress promotors', and 'Perceived unpleasant consequences'. CONCLUSION: The results indicated that the frequency of moral distress in operating rooms and surgical units was at a moderate level and the distress intensity of nurses was at a moderately high level. The results indicated that in the investigated system, the "inductive moral process of distress development" was continuously understood by the participants. This process was influenced by systemic and individual factors. Weak assertiveness, conservative compromise, and desensitization to unprofessionalism as individual factors were effective in causing distress. Risk factors at the systemic level led nurses to melt into the faulty system and created adverse outcomes at the individual level. The lack of systemic support and the stabilization of mobbing by powerful system members had a negative impact on the individual factors of distress development. Also, these factors directly cause negative consequences.

Nursing students' experience of moral distress in clinical settings: A phenomenological study.

AIM: To explore nursing students' moral distress (MD) experiences in clinical settings. DESIGN: An interpretative phenomenological analysis (IPA) design was employed. METHODS: Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method. RESULTS: Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity. CONCLUSION: Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Developing an evidence-and ethics-informed intervention for moral distress.

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic's trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach to develop a moral distress intervention-proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness.