Aims:The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distressBackground:Moral distress is said to occur when one has made a moral judgement but is unable to act upon it However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenonDesign:Systematic literature review and narrative synthesis (November 2015–March 2016)Data sources:Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO® 1967–Present, CINAHL® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education AbstractsReview methods:Literature relating to moral distress was systematically retrieved and subjected to relevanc

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What is 'moral distress'? A narrative synthesis of the literature

Objectives To describe the views of pharmacists and student pharmacists regarding (1) aspects of life and experiences that provide professional and personal satisfaction and fulfillment, (2) causes of stress, and (3) needs related to maintaining satisfaction and fulfillment. Design A generic qualitative research design was used for collecting data from 380 pharmacists and 332 student pharmacists who wrote responses to an online survey hosted by the American Pharmacists Association (APhA) from November 17 to December 2, 2018, using standard data collection procedures applied by that organization. APhA uses its member and affiliate data files as its sampling frame and limits the number of contacts per year for each person in those files. De-identified responses from those who volunteered to write comments were sent to the research team for analysis. A conventional content analysis approach was applied for analysis of the text. Analysts convened to discuss emergent themes and develop operational descriptions. Key segments of text that best represented each theme were identified. Personal presuppositions were disclosed and were useful for developing group consensus for theme identification and description. Rigor was supported through assessment of credibility, confirmability, intercoder checking, transferability, inductive thematic saturation, and authenticity. Setting and participants Participants are in the design since data already collected. Outcome measures Not applicable. Results Findings showed that pharmacists and student pharmacists are able to recognize and pursue achievement, recognition, responsibility, advancement, relationship, esteem, self-actualization, meaning, and accomplishment in both their professional and personal lives. However, external factors such as “workism” and individual factors such as “moral distress” were identified as areas of improvement that are needed for well-being and resilience. Conclusion Pharmacists’ basic human needs are being met, but to improve well-being and resilience for pharmacists in both their professional and personal lives, there is a need for addressing both the external factors and individual factors that they encounter.

Pharmacist and student pharmacist views of professional and personal well-being and resilience.

Ethical management with minimum moral distress is one of the main duties of nurse managers. There is no doubt that a better understanding of the experiences of nurse managers in morally challenging situations could have an effective role in improving health care systems. The present study aimed to investigate the lived experiences of clinical nurse managers regarding moral distress. This hermeneutic phenomenological qualitative research involved the use of semi-structured interviews with nurse managers. The interviews were transcribed and analyzed by the Diekelman, Allen and Tanner approach. For this purpose, a total of 14 Iranian nurse managers with at least five years of experience in nursing management in hospitals were purposefully selected. The findings related to nurse managers' experiences of moral distress contained two main themes (psycho-emotional trauma and professional desperation syndrome) and four sub-themes (shame, emotional dissociation, helplessness, impaired professional identity). The findings of the study indicated that in order to understand the phenomenon of moral distress among nurse managers, it is essential to investigate the moral distress experienced by them. We also found that although they experience moral distress in their daily decisions repeatedly, they are not fully aware of this phenomenon According to the results, for clinical nurse managers, moral distress is an ambiguous situation like suspension along with uncertainty, fear and so on. They believed that experiencing this kind of conscious mistake is the reason for the occurrence of professional desperation syndrome and psycho-emotional trauma.

The lived experiences of clinical nurse managers regarding moral distress.

Background Like other health professionals, community pharmacists are exposed to stress factors (being efficient, avoiding mistakes and bearing emotional load), but they are also under the pressure of entrepreneurial responsibilities. The main objective was to assess the level of work-related stress in French community pharmacies. The other objectives of the study were to assess the associated comorbidities and causes of work-related stress. Methods This observational cross-sectional study was sent to all French community pharmacies by email. The survey was anonymous and designed to collect the following items: socio-demographic factors, professional status, characteristics of community pharmacy, work-related stress (visual analogic scale-VAS), fatigue (VAS), sleep disturbances (questions), anxiety and depression symptoms (hospital anxiety and depression scale), medical consultation for work-related stress, medication use for work related stress, psychoactive drug-use and causes of work-related stress. Participants were included in the survey if they were pharmacists (owner or assistant) or pharmacy technicians working in a community pharmacy at the time of the survey. Exclusion criteria were defined as follows: pharmacy students or other professionals involved in a community pharmacy (e.g. dietician, beautician) and lack of professional status information. There was no age limitation. Results After three months of data collection, 1,339 participants answered the survey and 1,272 participants were included in conformity with the inclusion and exclusion criteria, and to avoid missing data on the primary endpoint. Work-related stress was detected in 32.8% (417/1,272) of individuals (scores ≥70/100). Men were significantly more affected than women and there was no difference between professional statuses and no relation with the age of the participants. Work-related stress was significantly associated with anxiety, depression, fatigue, sleep disturbances, medical consultations, medication use, alcohol consumption above the WHO recommendations for men and psychoactive drug use. Three causes of stress were clearly identified and related to stress levels, workload, working atmosphere and deterioration of work quality. However, causes of work-related stress were significantly different among professionals, for example: entrepreneurial burden for pharmacists-in-charge and workload for employees (assistant pharmacists and pharmacy technicians). Discussion Work-related stress has a very strong impact in French community pharmacies. This stress was associated with several comorbidities and induces health resource consumption. Several causes of work-related stress have been identified such as workload, working atmosphere and deterioration of work quality; however, these causes could be detected and managed to improve stress levels. We recommend developing individual and organizational stress management in French community pharmacies.

Work-related stress, associated comorbidities and stress causes in French community pharmacies: a nationwide cross-sectional study

Background Pharmacists work within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment creates the potential for moral distress to occur due to the limitations it places on acting in congruence with moral judgements. Very little research regarding this phenomenon has been undertaken in pharmacy: thus, prominent research gaps have arisen for the development of a robust tool to measure and quantify moral distress experienced in the profession. Objective The aim of this study was to develop an instrument to measure moral distress in community pharmacists. Setting Community pharmacies in the United Kingdom. Method This study adopted a three-phase exploratory sequential mixed-method design. Three semi-structured focus groups were then conducted to allow pharmacists to identify and explore scenarios that cause moral distress. Each of the identified scenarios were developed into a statement, which was paired with twin seven-point Likert scales to measure the frequency and intensity of the distress, respectively. Content validity, reliability, and construct validity were all tested, and the questionnaire was refined. Main outcome measure The successful development of the valid instrument for use in the United Kingdom. Results This research has led to the development of a valid and reliable instrument to measure moral distress in community pharmacists in the UK. The questionnaire has already been distributed to a large sample of community pharmacists. Conclusion Results from this distribution will be used to inform the formulation of coping strategies for dealing with moral distress.

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Development and validation of a questionnaire to measure moral distress in community pharmacists.

Objectives

Moral distress arises from situations in which the individual identifies the morally right action required, but feels unable to act accordingly due to organisational constraints within the work place. Research into this phenomenon has focused predominately on the experience of those in the nursing profession, due to its perceived moral grounding and its traditionally subordinate role. As the conceptual boundaries of moral distress have developed, so too has the research interest in the experiences of other professional groups. Here, we seek to determine if there is scope to study moral distress in pharmacists.



Methods

A review of the literature on moral distress in healthcare professions was undertaken.



Key findings

Pharmacists working in the UK operate within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment, when combined with the emerging recognition that pharmacy is a value-based profession with a strong ethical grounding, creates the potential for moral distress to occur due to the limitations placed on acting in congruence with ethical judgements. Studies concerning moral distress in nurses have identified significant negative consequences for both the practitioner and for the quality of patient care.



Conclusions

To date, the incidence of moral distress among UK-based community pharmacists remains unexamined. Research must be undertaken to determine what situations cause the highest instances of moral distress for community pharmacists, and the extent to which these pharmacists experience moral distress in their working lives.

The issue of moral distress in community pharmacy practice: background and research agenda

Negotiating the parallel imports rules

The dispensing of parallel imports (PIs) generates heated debate among patients, prescribers and pharmacists. Many people will have come across PIs, but their legal standing is little understood among those who most frequently encounter them. A PI is a legitimately produced medicinal product imported into the UK from another EU member state without the permission of the owner of the intellectual property rights that attach to the product in its country of origin. The intellectual property rights for a medicine are typically owned by its manufacturer (the holder of the manufacturing authorisation). PIs are imported into one member state from another and placed on the market, outside the formal channels of the manufacturer or its licensed distributor. Parallel imports tend to occur when price levels for similar products between two member states are significantly different.This creates an incentive for traders to buy products in the member state where they are priced lower and sell them in the member state where they are priced higher. A modified form of licensing procedure may be considered for a PI provided it is covered by a valid marketing authorisation (MA) in an EU member state, has no different therapeutic effect to that of its UK-licensed equivalent, and is made by (or under licence to) the UK manufacturer or the same group of companies. This article will examine the genesis of the parallel trade in medicines and visit the landmark EU cases that set the criteria for the licensing of these products.

Richard O'neill

Papers

The issue of moral distress in community pharmacy practice: background and research agenda

Negotiating the parallel imports rules

Birth of the parallel medicines trade