We also thank Robin Hermann for sharing her clinical examples of moral distress and the unique stressors that arise in clinical practice in nursing care for patients and families. Some worry that if the rising tide of moral distress is not addressed, the professional and moral integrity of health professionals is at risk.
The Organization of the Book
Ethical climate, ethical stress, and the job satisfaction of nurses and social workers in the United States. Physician-related barriers to communication and patient- and family-centered end-of-life decision-making in the intensive care unit: a systematic review.
What We Know About Moral Distress
- Moral Distress: Evolution of the Concept
- Conceptual Origin and Evolution of the Definition
- Challenges and Critiques of the Definition
- Appreciating the Reciprocity of Structure and Agency Scholars and researchers in moral distress are increasingly calling for a relational
By this we mean that the definition of moral concern must be shifted beyond the level of the individual. Unable to answer our patients' call: mental health nurses' experience of moral distress.
Healthcare Professional Narratives on Moral Distress: Disciplinary
Contributors
Contributors
- Reviews of Moral Distress in Nursing and in Social Work .1 Moral Distress in Nursing: Looking Back to Move Forward
- Introduction
- The Moral Milieu of an Institution: Predecessor Literature
- Shaping and Re-Shaping the Moral Milieu
- Ethics Education and Enduring Issues in Nursing
- Various Critiques of Moral Distress
- Conclusion
- Social Work Perspective: Moral Distress Sophia Fantus
- Part 2: Healthcare Professional Perspectives .1 A Source of Moral Distress: The Corporatization
- Moral Distress: A Psychiatrist Perspective Michelle Joy
- A Chaplain’s Perspective on Moral Distress Margaret Lindsey
- Moral Distress in Pediatric Nursing and Research Kim Mooney-Doyle
- Pharmacist’s Perspective on Moral Distress in Palliative Care: A Narrative
Essential to the theory of moral distress is the assumption that such a state of distress actually exists. Addressing the concept of moral distress in social work has important implications for both education and practice.
A Broader Understanding of Moral Distress
- The Case for Broadening Our Understanding of Moral Distress
- Moral Uncertainty
- Mild Distress
- Delayed Distress
- Moral Dilemma
- Bad Moral Luck
- Distress by Association
- A New Definition of Moral Distress
- Is It Too Broad?
- Toward a Taxonomy of Moral Distress
- Conclusion
It merely suggests that this previous work has focused on one type of moral distress. There are some notable contrasts between our proposed definition and the traditional understanding of moral distress. Importantly, we do not claim that all forms of moral distress require or deserve intervention.
These authors raised concerns about the practical effects of abandoning the traditional understanding of moral distress.
Sources of Moral Distress
Introduction
Because this interrelationship extends beyond healthcare practice, it is imperative to understand the sources of moral distress and address the negative consequences for professionals and organizations toward the goal of achieving the best possible health outcomes for patients and communities .
Major Root Causes of Moral Distress
- Clinical Situations
- Technology
- Care Near the End of Life
- Interprofessional Practice
- Hastening the Dying Process
- Internal Constraints .1 Individual
- Professional Socialization
- Perceived Powerlessness
- Ethics Knowledge
- External Constraints
- Person- and Family-Centered Care
- Following Family Wishes for Patient Care for Fear of Litigation
- Professionalism
- Policies and Priorities
- Organizational Values and Ethical Climate
- Societal Factors
Nursing practice in intensive care units was fundamental to the identification and early study of the phenomenon of moral distress. Moral distress can be experienced wherever and whenever physicians are required to provide health care. Moral distress in the third year of medical school: A descriptive review of student case reflections.
A qualitative study investigating moral distress in the ICU team: the importance of unit functionality and intrateam dynamics.
Building Compassionate Work Environments: The Concept
- Building Compassionate Work Environments
- Measure of Ethical Climate: The Hospital Ethical Climate Survey (HECS, [1])
- Conditions for Ethical Reflection in Organizations .1 Power and Trust
- Inclusion
- Role Flexibility and Inquiry
- Ethical Climate or Ethical Culture
- Research
- The Relationship Between Ethical Climate and Moral Distress
- Ethical Climate and Turnover Intention and Job Satisfaction
- Summary and Conclusion
The Hospital Ethical Climate Survey (HECS) is a 26-item survey in which the items or variables are categorized into five key relationships that nurses and all healthcare professionals have within the work environment: colleagues, managers, doctors, patients and families, and the hospital (or relevant healthcare organization ). The way in which nurses perceive the ethical climate in their work environment is thus inversely related to moral distress. Of the five dimensions measured by the Hospital Ethical Climate Scale, the score is
Positive perceptions of the ethical climate can mitigate the impact of moral distress associated with difficult and complex ethical issues in the healthcare workplace.
Moral Distress Research Agenda
Introduction
In this chapter, we draw on a socioecological perspective to propose a research agenda for moral distress. Others have noted that the relationship between major moral distress concepts such as moral agency and ethical climate deserves further investigation [11]. Our goal is to consider moral distress within the constructs of time and space and a larger context of moral obligations, agency, and integrity.
Finally, we propose a monitoring apparatus to assess progress in the science of moral distress in a systematic, coordinated, and collaborative effort.
A Theoretical Perspective for Researching Moral Distress
Mechanisms to support clinicians appear in health care organizations, but their impact on reducing moral distress needs further study. Taken together, ecological constructs such as embodiment, path, moderating factors, cumulative interactions, accountability and agency broaden our avenues for research methods such as factor analysis, correlational analyses, structural equation modeling (e.g. See Rathert [19]) and intervention from studies that manipulate internal and external factors to build improved roads. As recently noted by Elizabeth Peter, "It is not that moral distress is no longer relevant, but we need to expand our understanding through additional concepts that help us understand the ethics of nursing work with its frequent proximity to patients and its political position in a variety of institutions” [20] (p. 3).
The spatial-temporal concepts from the social-ecological perspective potentially broaden our study of moral distress without diluting or devaluing the concept's significance for clinical practice.
A Socioecological Research Agenda for Moral Integrity and Moral Distress
- Defining and Measuring Moral Distress
- Exploring Moral Integrity
- Expanding the Study of Moral Distress
- Examining the Concept of Moral Community
- Impact of Moral Spaces: Ethics Rounds to Promote Moral Community
Items in the classic Moral Distress Scale Revised (MDS-R) are still being assessed for relevance, validity and reliability [25]. For example, Traudt and colleagues examined the experiences of critical care nurses who managed to successfully “avoid or navigate through” moral distress [ 33 ] (p. 202). Researchers have primarily examined moral distress as a concept and experience of nurses, physicians, and other members of the health care team.
Thus, any kind of moral community requires an interprofessional team, and functional teams are clearly a primary prevention strategy against the development of moral distress.
A Research Agenda for Action on Moral Distress
- Primary Prevention Strategies for Moral Distress
- Speaking Up Policy
- Collaborative Governance: Ethics in Clinical Practice Committee
- Policy Development for Patients Approaching End of Life
- Proactive Collaboration for Patients Who Are Chronically Critically Ill
- Risk Reduction Strategies for Moral Distress
- Ethics Early Action Protocol
- Clinical Ethics Residency for Nurses
- Mitigation and Treatment Strategies for Moral Distress
- Moral Distress Consultation Service
- Healing from Moral Distress
Research has documented that unresolved end-of-life issues contribute significantly to nurses' moral distress. Hamric and Epstein report on the development and evaluation of the Moral Distress Counseling Service (MDCS) [14]. Post-retreat evaluations indicated that participants increased their awareness of moral distress among clinicians of all disciplines.
These differences point to the need for more in-depth research on moral decision-making and moral distress among patients, family, and surrogates.
Final Thoughts on Researching Moral Distress
Tabulating the accumulating evidence (see Example Table 7.1) will reveal important gaps and strengths for researchers in moral distress. Development and psychometric testing of a new tool for detecting moral distress: the moral distress thermometer. When health professionals can't do the right thing: a systematic review of moral distress and its correlates.
Clinical ethics residency for nurses: an education model to decrease moral distress and strengthen acute care nurse retention.
International Perspectives on Moral Distress
International Perspectives on Moral Distress
Healthcare physicians in every medical, surgical, and intensive care hospital unit in the United States and abroad experience moral distress. This chapter shares international perspectives on moral distress of doctors and nurses from Africa, Asia and Europe. In these essays, the stories of moral problems are (in many ways) similar to the experiences of American clinicians.
In this essay, she poignantly emphasizes the moral distress she felt as a daughter who was also a nurse.
European Perspectives on Moral Distress An LievrouwBo Van den Bulcke, Dominique Benoit, and Ruth Piers
- Moral Distress Studies in Europe
- From Individual Caretaker Viewpoint to Team Perspective In Europe, moral distress is mostly studied in nurses [1], assuming that they are
- Results of the APPROPRICUS Study
- Conclusion
Additionally, many studies use the moral distress scale [5], presenting situations that are closely related to a North American context [6]. European nurses typically have higher levels of moral distress than physicians [11]; and, often feel unable to change the plan of care for their patients [10] and perceive limited control over unit operations and management issues [4]. Successfully managing morale distress can be an opportunity to transform and grow a team.
However, an important common ground for moral distress is the perception of overtreatment, particularly in end-of-life care.
Speaking Truth to Power
I came across a study on moral distress in the United States of America (US) and was surprised that it was being researched so extensively. It is no wonder that nurses have been so fascinated by the phenomenon of moral distress, as it captures so well their everyday experiences of marginalization and disempowerment. However, the loss of moral distress for nurses risks losing a weapon from our arsenal as it has been the driver of change in the US and I hope the same will be true for the UK.
The effectiveness of the nurse ethicist in reducing moral distress: what can the NHS learn from the USA.
Moral Distress in the Provision of Health Care in Tanzania: Developing World Perspective
In developing countries, health workers can become morally impaired due to the various ethical dilemmas they face in their daily working life. Informed consent is also not clearly understood in developing countries, and especially its importance in the relationship between patient and provider. Severe shortages of material and human resources in developing countries place an undue burden on health workers [57], which can lead to moral distress and the loss of dedicated professionals [58].
In order to improve patient outcomes and reduce the moral distress of healthcare workers in developing countries, there is an urgent need to improve working conditions.
Truth Telling and Moral Distress : A Singaporean Perspective
- Introduction
- Truth-telling and Moral Distress in the Singapore Context Jameton [92] (p. 297) defines moral distress as “when individuals have clear
- Moral Distress in the Personal Space: The Nurse as the Family Caregiver
- Final Thoughts…
In this chapter we explore the issue of moral distress and truth telling in the Singaporean context. Moral distress arises when there is a mismatch between congruence of care and the nurse's professional ethics and values. In this section we want to move the discussion about moral distress within the personal context of the nurse.
We have learned that the dual role of nurse – that of family member and nurse – creates fertile ground for moral distress and moral ambiguity.
Reflections on Moral Distress and Moral Success
Significant Reasons for Moral Distress
He says: “In my experience, the single most important source of moral distress is the feeling of powerlessness. She says: “The experience of moral distress is an individual (or, in some cases, group) response to a structural problem of complex organizations, especially health care systems. Shaké Ketefian (Professor Emerita, University of Michigan, and a pioneer in nursing ethics) also cites lack of power and lack of support as important sources of moral distress.
Box 9.2 Sheila Davis - The moral dilemma faced by medical volunteers treating Ebola patients in Sierra Leone.
Examples of Moral Success
Moral distress is emerging as a critically important issue for the psychological and physical well-being of clinicians, and especially those working in critical care settings. Ann Hamric and Elizabeth Epstein describe a path to promoting moral success through a moral emergency counseling service. Rushton also notes the need for additional conceptual work to help refine the meaning of moral resilience and how to find ways to employ resilience to mitigate the negative effects of moral distress.
Moral concern has created a certain sense of "shared identity" among health care physicians, and perhaps shared experiences, stories, and power can foster collective resilience.
Summary
Cynda Rushton (a prominent nurse bioethicist at Johns Hopkins University) has championed a concept of "moral resilience." Rushton and Alisa Carse note that. It is critical that we find ways to empower clinicians to heed this call to support clinicians' moral agency and voice, foster their moral resilience, and facilitate their ability to contribute to needed reforms within the organizations and systems that they work in" [3 ]. Facing adversity, building resilience and finding joy." [5] Although their focus is not on health care or health care provider moral distress, they note that "by helping people cope with difficult circumstances and then taking steps to change those circumstances, collective resilience can promote real social change." ([5], p. 135).
According to them, “collective resilience requires more than just shared hope – it is also fueled by shared experiences, shared stories, and shared power” (p. 130).
