Moral distress in nursing: Contributing factors, outcomes and interventions

doi:10.1177/0969733012462049

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Moral distress in nursing: Contributing factors, outcomes and interventions

Journal Article•DOI•

Moral distress in nursing: Contributing factors, outcomes and interventions

Adam Burston¹, Anthony G. Tuckett¹•Institutions (1)

University of Queensland¹

01 May 2013-Nursing Ethics (SAGE Publications)-Vol. 20, Iss: 3, pp 312-324

TL;DR: An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these.

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Abstract: Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview resides in the implications moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention.

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Journal Article•DOI•

When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates:

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Giulia Lamiani¹, Lidia Borghi¹, Piergiorgio Argentero²•Institutions (2)

University of Milan¹, University of Pavia²

01 Jan 2017-Journal of Health Psychology

TL;DR: It is revealed that moral distress negatively affects clinicians’ wellbeing and job retention and further studies should investigate protective psychological factors to develop preventive interventions.

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Abstract: Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians’ wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.

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286 citations

Journal Article•DOI•

Moral distress in intensive care unit professionals is associated with profession, age, and years of experience☆

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Peter Dodek¹, Hubert Wong¹, Monica Norena¹, Najib T. Ayas¹, Steven Reynolds¹, Sean P. Keenan¹, Sean P. Keenan², Ann B. Hamric³, Patricia Rodney¹, Miriam Stewart⁴, Lynn E. Alden¹ - Show less +7 more•Institutions (4)

University of British Columbia¹, Royal Columbian Hospital², Virginia Commonwealth University³, St. Paul's Hospital⁴

01 Feb 2016-Journal of Critical Care

TL;DR: Moral distress is higher in ICU nurses and other non-physician professionals than in physicians, is lower with older age for other non thephysicians professionals but greater with more years of experience in nurses, and is associated with tendency to leave the job.

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167 citations

Cites background from "Moral distress in nursing: Contribu..."

...Although interventions to prevent or ameliorate moral distress are only beginning to emerge [8,27], there are growing indications that reducing moral distress may lead to tangible benefits such as increased staff retention and improved inter-professional teamwork [8,13]....
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Journal Article•DOI•

Moral distress in physicians and nurses: Impact on professional quality of life and turnover.

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Cindy L. Austin¹, Robert Saylor¹, Phillip J. Finley¹•Institutions (1)

Mercy Medical Center (Baltimore, Maryland)¹

01 Jul 2017-Psychological Trauma: Theory, Research, Practice, and Policy

TL;DR: It is suggested that the presence of MD significantly impacts turnover intent and professional quality of life, and implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

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Abstract: Objective The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital Method Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale-Revised and Professional Quality of Life Scale) Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one's professional quality of life Relationships between these constructs and clinicians' years in health care, critical care patient load, and professional discipline were explored Results The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD Scores associated with intentions to leave or stay in a position were indicative of high verses low MD We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50% Conclusion The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life Therefore implementation of emotional wellness activities (eg, empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted (PsycINFO Database Record

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151 citations

Journal Article•DOI•

Moral distress in critical care nursing: The state of the science:

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Natalie S. McAndrew¹, Jane Leske¹, Kathryn Schroeter¹•Institutions (1)

Medical College of Wisconsin¹

01 Aug 2018-Nursing Ethics

TL;DR: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015 and revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, and few effective interventions.

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Abstract: Background Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review methods This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. Results Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.

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133 citations

Cites background from "Moral distress in nursing: Contribu..."

...While moral distress may be a negative experience for many nurses, it can also increase autonomy and result in professional growth and development.(5,13,16,56,70) Critical reflective practice(40) may be an intervention to help nurses identify the complexities of the moral distress experience and develop strategies to cognitively reframe the situation....
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...nurse outcomes.(13) A major omission of prior reviews is specificity to the critical care practice area....
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...Attention to moral distress in this practice area is important given the frequency ethical conflict occurs(10) and the impact on nurses, patients, and families.(1,8,12,13,16,23,24) These factors provide the rationale for an exploration of quantitative and qualitative literature....
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...Critical care nurses are at high risk for moral distress due to ethical conflicts created by technological advancement, high-intensity work environments, and frequent exposure to death.(13,21,22) Attention to moral distress in this practice area is important given the frequency ethical conflict occurs(10) and the impact on nurses, patients, and families....
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Journal Article•DOI•

Toward interventions to address moral distress Navigating structure and agency

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Lynn Corinne Musto¹, Patricia Rodney¹, Rebecca Vanderheide²•Institutions (2)

University of British Columbia¹, Monash University²

01 Feb 2015-Nursing Ethics

TL;DR: The posit moral distress as a form of relational trauma and the need to better understand how nurses as moral agents are influenced by—and influence—the complex socio-political structures they inhabit are pointed to.

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Abstract: Background:The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience.Discussion:Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress.Conclusion:We posit moral distress as a form of relational trauma and subsequently point to the need to better understand ...

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120 citations

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References

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Open Access

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Book•

Qualitative Research Methods

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Pranee Liamputtong

14 Apr 2005

TL;DR: Theoretical Frameworks and Sampling in Qualitative Research as discussed by the authors have been used extensively in the field of qualitative research, and they have been applied to a wide range of applications in a variety of domains.

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Abstract: Introduction Part 1 Background to Qualitative Research 1. Theoretical Frameworks and Sampling in Qualitative Research 2. Rigour and Ethics in Qualitative Research Part 2 Types of Qualitative Research Methods 3. In-depth Interviewing Method 4. Focus Groups 5. Unobtrusive Methods 6. Narrative Inquiry Methodology: Life and Oral History, Life Story and Biographical Research. 7. Memory-work 8. Ethnography 9. Participatory Action Research 10. Qualitative Case Study Research 11. Grounded Theory Research Part 3 Applications of Qualitative Research 12. Researching the 'Vulnerable' 13. Going Online: Doing Qualitative Research in Cyberspace 14. Making Sense of Qualitative Data: Analysis Process 15. Writing a Qualitative Research Proposal 16. Writing a Qualitative Research Report 17. Qualitative Research: New Directions Glossary References

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4,352 citations

Book•

Nursing practice : the ethical issues

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Andrew Jameton

01 Jan 1984

1,076 citations

Journal Article•DOI•

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate.

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Ann B. Hamric¹, Leslie J. Blackhall•Institutions (1)

University of Virginia¹

01 Feb 2007-Critical Care Medicine

TL;DR: Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

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Abstract: Objective:To explore registered nurses’ and attending physicians’ perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.Desig

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668 citations

Journal Article•DOI•

Nurse Moral Distress and Ethical Work Environment

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Mary C. Corley¹, Ptlene Minick², Ronald K. Elswick¹, Mary Jacobs³•Institutions (3)

Virginia Commonwealth University¹, Georgia State University², Veterans Health Administration³

01 Jul 2005-Nursing Ethics

TL;DR: A difference between moral distress intensity and frequency and the importance of the environment tomoral distress intensity is revealed.

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Abstract: This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with moral distress intensity, whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity.

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607 citations

"Moral distress in nursing: Contribu..." refers background or result in this paper

...Corley et al.(22) implore administrators to particularly target those experiencing high levels of moral distress intensity....
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...First, unsafe staffing levels have been found to contribute to the highest intensity and frequency of moral distress.(22) Typically, the highest intensity of moral distress is related to low staffing levels within the ward....
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...note that this high frequency (but low intensity) is in contrast to previous findings of other researchers such as Corley et al.(22) who identified low frequency but high intensity of moral distress in the acute care (non-psychiatric) environment....
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...Ohnishi et al.32 note that this high frequency (but low intensity) is in contrast to previous findings of other researchers such as Corley et al.22 who identified low frequency but high intensity of moral distress in the acute care (non-psychiatric) environment....
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...Others, however, identified no correlation between nursing experience (along with other demographic detail) and moral distress.18 Corley et al.22 describe a significant but low negative correlation between age and moral distress intensity; however, they suggest that experience alone is of only limited help in dealing with it....
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Journal Article•DOI•

Living with conflicts-ethical dilemmas and moral distress in the health care system

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Sofia Kälvemark¹, Anna T. Höglund¹, Mats G. Hansson¹, Peter Westerholm, Bengt B. Arnetz¹ - Show less +1 more•Institutions (1)

Uppsala University¹

01 Mar 2004-Social Science & Medicine

TL;DR: The results show that the study of moral distress must focus more on the context of the ethical dilemmas, and that the work organization must provide better support resources and structures to decrease moral distress.

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577 citations

"Moral distress in nursing: Contribu..." refers background in this paper

...Kälvemark et al.(49) identify a lack of beds for patient care delivery and others an inappropriate environment for the provision of palliative care(47) as contributing factors....
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...Similarly, a lack of time to do what ought to be done is also blamed.(43,49,52)...
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...It is viewed as a multidisciplinary issue and is evident where ‘ . . . unit, team, or institutional/system dynamics continue to be unaddressed’ (p. 333).74 An additional and dominant workplace consequence of moral distress is the issue of retention and staff shortages.42 Nurses not only think about leaving their current position but also consider leaving the nursing profession altogether;21 and others do change jobs30,31 and leave the profession.71,72 It is obvious then that moral distress has a negative effect on organizational culture.68 Perhaps even more worryingly, Kälvemark et al.49 identified instances of practitioners either being forced to act or voluntarily breaking the rules, due to system-based limitations....
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...Perhaps even more worryingly, Kälvemark et al.(49) identified instances of practitioners either being forced to act or voluntarily breaking the rules, due to system-based limitations....
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...Kälvemark et al.49 identify a lack of beds for patient care delivery and others an inappropriate environment for the provision of palliative care47 as contributing factors....
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