The purpose of this research was to describe the experience of moral distress among regulated and unregulated nursing personnel employed in Long Term Care (LTC) facilities. The specific research questions were: 1) Do regulated and unregulated nursing personnel experience moral distress? 2) What is the nature of moral distress in LTC facilities? 3) How do nursing personnel describe and perceive the experience of moral distress? 4) What are the organizational factors that participants perceive as contributing to or reducing moral distress in their workplace? A qualitative, descriptive, study design was used. Semi-structured interviews were the method of data collection and analysis was conducted using thematic content analysis as proposed by Miles and Huberman’s (1994). A purposive sample of 16 participants was recruited from two LTC facilities. Participants described work experiences in which they felt they were unable to do the “right thing”. There were four kinds of situations that gave rise to moral distress: end of life care, resident behaviours, other direct care provider behaviours and the work environment. The experience of moral distress was described in terms of an initial emotional reaction, followed by a response, with resolved or unresolved outcomes. Half of the examples described by participants as giving rise to moral distress, remained unresolved. Participants also identified organizational factors that prevented moral distress and assisted with its resolution such as, educational courses, administrative leadership and pastoral support. / Thesis (Master, Nursing) -- Queen's University, 2010-09-24 13:59:20.125

With the corporatization of healthcare, combined with rapid advances in medical technology, frontline health care workers, especially nurses, are facing an increase in daily ethical dilemmas, with potential increases in moral distress. The contributing factors and negative effects of moral distress are well researched, in particular as they impact nurses in specialty areas. However, understanding how nurses navigate moral distress, specifically in general medical and surgical units, is not as well understood. The purpose of this study was to understand and articulate the processes that nurses carry out when navigating moral distress, by exploring their interactions with the health care environment. Using grounded theory methodology, a substantive theory was developed to explain the process. The participants in this study were all registered nurses from an acute care academic hospital, who worked on non-specialty medical and/or surgical units. Data collection consisted of audio-recorded face-to-face interviews that were transcribed post interview. All the events and situations that resulted in the experience of moral distress were primarily rooted in organizational structures, which often blindsided the nurses in this study, and led to a sense of feeling ill-equipped and unsupported to respond in the moment. Furthermore, the participants expressed their inability to be agents of change due to the established organizational expectations. The basic social process for navigating moral distress was “Just getting through the shift”. This theory is comprised of the categories of Experiencing Moral Distress, Making Sense of the Situation, and Finding the Way. In working through these processes, the participants engaged in navigating moral distress. Making sense of the situation was an ongoing process that nurses engaged in whereby they sought out knowledge in various ways, such as exploring internal resources, and building relationships with their peers, their patients, and patients’ families. Throughout this iterative process of making sense of the situation, the nurses were then able to find their way. Participants discussed positive outcomes such as reflecting and learning from the experience. However, despite this response, there was a feeling of powerlessness to make a difference. Therefore, they focused on providing the best care they could and getting on with their shift without experiencing closure. / Graduate

Moral distress is a negative emotional and somatic response to external constraints on moral action. The constraints are typically identified as a component of the work environment, called the ethical climate. Moral distress is identified as a primary reason for job attrition by up to one-quarter of registered nurses who leave their jobs. One strategy suggested to staff nurses who experience moral distress is to consult their Nurse Manager (NM). However, the moral distress of NMs who are employed in acute care hospitals is poorly understood. The purpose of this qualitative study was to examine NMs' perceptions of the external constraints on moral agency, specifically the hospital ethical climate, which leads to their experience of moral distress and how attributes of the ethical climate facilitated or impeded resolution of their moral distress. Semi-structured, audio-recorded telephone interviews were conducted with 17 NMs from across United States. An interpretive description design using an iterative process between data collection and data analysis was used. Data were analyzed through descriptive coding and thematic analysis. The participants in this study were 15 women and 2 men with a mean age of 46.4 years. The mean length of time in their current positions was slightly less than 5 years. Of the 17 hospitals represented, 6 were affiliated with a university and 4 had a religious affiliation. Fifteen of 17 NMs described situations in which the implicit and explicit values of the hospital were incongruent with their personal moral values and professional ethics. Common themes describing factors contributing to moral distress were administrative policies, negative communication patterns and relationships with physicians, issues related to staff nurses, issues related to patients and families, and multiple competing job obligations. Respondents described strategies to navigate through their moral distress. The strategies included taking a positive perspective, seeking the advice of NM colleagues, reliance on a positive relationship with a supervisor, and talking it through with family members. For 5 of the 15 NMs who experienced moral distress, their final strategy included plans to resign from their positions. Issues within the ethical climate of the hospital that were perceived to contribute to the development of moral distress among this cohort of NMs differed from those reported for staff nurses. Further examination of strategies used by NMs to improve the ethical climate may yield insights into effective ways to address moral distress for this population.

The purpose of this study was to examine how nurses' critical reflective practice, education level, and moral distress related to their work engagement. This is an area of study relevant to nursing, given documented United States Registered Nurse (RN) experiences of job related distress and work dissatisfaction, and the nursing shortage crisis. Nurses are central players in the provision of quality health care. There is need for better understanding of RNs' work engagement and factors that may enhance their work experience. A theoretical framework of critical reflective practice was developed and examined in this study.A non-experimental, descriptive, correlational design was used to examine the relationships among four study variables: critical reflective practice, education level, moral distress, and work engagement. The purposive sample consisted of 28 intensive care unit RNs (ICU-RNs) from three separate ICUs (medical, neonatal, and pediatric) in a 355-bed Southwest magnet-designated hospital. Measures of the key variables were as follows: (1) Critical Reflective Practice Questionnaire (CRPQ) developed for this study; (2) a subscale of Mary C. Corley's Moral Distress Scale; (3) Education level measured as the highest nursing degree earned to practice as a RN; and (4) the Utrecht Work Engagement Scale. All instruments demonstrated adequate reliability and validity.Pearson correlation and multiple regression analyses indicated support for the theoretical framework: There was a negative direct relationship between moral distress and work engagement, a positive direct relationship between critical reflective practice and work engagement, and moral distress and critical reflective practice, together, explained 47% of the variance in work engagement. Additionally, in the NICU, results indicated a positive direct relationship between increased educational level and critical reflective practice. Results also indicated that moral distress was a clinically significant issue for ICU-RNs in this sample.Strategies to promote critical reflective practice and reduce moral distress are recommended. Additionally, the findings support continued study of critical reflective practice and moral distress, and the role of education level, in nurses' work engagement. Research goals include continued study of the theoretical framework in larger study samples and in reference to additional explanatory factors.

The moral distress experiences of Registered Nurses who work in non-acute, continuing care settings were examined using qualitative methods. Previous research suggests that in general, nurses experience moral distress when they are not able to pursue actions in accordance with their moral conscience. Moral distress in nurses is expressed negatively in both the nurses’ professional and personal lives. However, most research on moral distress among nurses has focused on acute care settings. Registered Nurse participants were recruited from non-acute continuing care settings and described their experiences of moral conflict and distress. Particular attention was placed on the nurses’ experiences and reactions to their experience. The findings from this study indicated that as in other settings, moral distress is present in Registered Nurses practicing in non-acute continuing care. The nurses’ practicing in non-acute continuing care settings experienced moral distress after facing a barrier to their moral conscience involving organizational functioning, end of life decisions, patient advocacy, and resource utilization. Nurses experienced feelings including powerlessness, concern, regret, disappointment, suspicion of others, and feeling devalued. Future studies may focus further on the subspecialties in the non-acute continuing care sector. Research on strategies to resolve moral distress and research on the effectiveness of current interventions to combat moral distress among Registered Nurses in this setting should be pursued. / Thesis (Master, Nursing) -- Queen's University, 2009-09-01 10:02:08.043

The purpose of this research was to explore the process used by mental health nurses working with adolescents to ameliorate the experience of moral distress. Using grounded theory methodology, a substantive theory was developed to explain the process. All the incidents that lead to the experience of moral distress were related to safety and resulted in the nurse asking themselves the question, “Is this the best I can do?” Engaging in dialogue was the primary means nurses used to work through the experience of moral distress. Engaging in dialogue was an ongoing process and nurses sought out dialogue with a variety of people as they tried to make sense of their experience. Participants identified qualities of dialogue that were helpful or unhelpful as they sought to resolve their moral distress. Participants who had a positive experience of dialogue were able to answer the question, and continue working with adolescents with a renewed focus on the therapeutic relationship. Participants who have a negative experience of dialogue are unable to answer the question and either leave the unit or agency, or talk about leaving. / Graduate

Bakgrund: Den moraliska stressen är ett vanligt förekommande tema inom sjukvården idag och en av de drabbade professionerna är sjuksköterskor. Moralisk stress upplevs av en individ då den upplever att den agerar felaktigt, men på grund av situationen känner sig oförmögen att agera annorlunda. Denna påfrestning kan ha stor påverkan på vården och påverka både patienter och sjuksköterskor mycket negativt. Säker vård är en av sjuksköterskans kärnkompetenser, därmed är undanröjande av den moraliska stressen samt säkerställandet av patientsäkerheten av stor vikt.Syfte: Att belysa sjuksköterskors erfarenheter av moralisk stress.Metod: Studien genomfördes som en kvalitativ litteraturstudie vars syfte besvarades genom analys av 13 artiklar med kvalitativ ansats. Studien utfördes enligt Polit & Beck:s (2014) sju steg för skapande av litteraturstudie.Resultat: Nästan samtliga sjuksköterskor i de valda artiklarna hade ett flertal gånger upplevt moralisk stress. Organisatoriska brister, etiska dilemman och konflikter mellan kollegor, ansågs vara de främsta situationerna där moralisk stress uppstod. Sjuksköterskors personliga erfarenheter av den moraliska stressen kunde innehålla en variation av känslomässiga svar och ett flertal sjuksköterskor uppgav att de ansåg att den moraliska stressen hade förändrat både dem och professionen. Sjuksköterskor besvarade den moraliska stressen olika, men författarna kunde tydligt se två olika beteendemönster, ett konfronterande och ett undvikande beteende.Slutsats: Moralisk stress kan uppstå i en stor andel situationer och förekommer troligen hos de flesta sjuksköterskor. De flesta sjuksköterskor upplever moralisk stress som en överväldigande känsla och att de inte bara påverkar dem själva utan även deras patienter. Det främsta sättet att hantera moralisk stress var genom dialog med andra. Sjuksköterskor upplevde att den moraliska stressen förändrade både dem själva och professionen. Många sjuksköterskor eftersökte organisatoriskt stöd. / Background: Moral distress is considered a common theme in health care today and one of the affected professions are nurses. Moral distress is experienced when an individual feels that they are acting incorrectly, but due to the situation feels incapable to act differently. This pressure can have great affect on health care and can influence both patients and nurses negatively. Safe care is one of the nurses’ key competences, therefore is the eradication of the moral distress and ensuring patient safety of great importance.Aim: To illuminate nurses’ experiences of moral distress.Method: The study was conducted as a qualitative literature review and its aim was answered by analyzing 13 articles with a qualitative approach. The study was created according to Polit & Beck’s (2014) seven steps for creation of a qualitative literature review.Results: Almost all nurses reported that they had a number of times experienced moral distress. Organizational defaults, ethical dilemmas and conflict between colleagues, were primary situations where moral distress appeared. The nurses’ personal experiences of the moral distress could entail a variety of emotional responses and a number of nurses thought that the moral distress had changed both them and the profession. Nurses answered to the moral distress differently, but both authors could clearly see two different behavioral patterns, a confrontational and an evasive behavior.Conclusion: Moral distress can be experienced in a variety of different situations and is likely to be experienced by most nurses. Moral distress is mostly experienced as an overwhelming feeling and it affects both their patients as well as themselves. The primary method to cope with the moral distress is through dialogue with others. Nurses experienced that the moral distress changed both themselves as the nursing profession. Many nurses sought organizational support.

<p>The aim of the present literature study was to describe the significant factors contributing to the development of moral distress and the consequences of moral distress can lead to in the nurse profession. A literature search was performed in the databases Medline through PubMed and Academic Search Elite on the basis of in advanced defined criterions. A total of 19 articles was reviewed and included in the study. The main result revealed that nurses experience moral distress and that it is frequent within the nurse profession. The findings revealed that there seem to be several significant factors in the development of moral distress, such as providing life-sustaining care, competing loyalties, conflicts with the physician, communication barriers, emotional barriers, cultural barriers, regulation and rules and working environment that gives the nurse difficult or unsolved ethical dilemmas. The consequences of moral distress can contribute to health problems both physical symptoms and mentally, such as headache, neck and muscle pain, stomach problems, depression, anger and guilt. Moral distress affects the nurse professionally, and contributes to distancing from patients, relatives and colleagues, a resistance against going to work and to perform work tasks. The conclusion is that the consequences of moral distress don’t just affect nurses but undeniably also patients, relatives and other instances in within the healthcare system.</p> / <p>Syftet med denna litteraturstudie var att beskriva de faktorer som har betydelse för utvecklingen av moral distress, och vilka konsekvenser moral distress kan leda till i sjuksköterskans yrkesutövning. En litteratursökning genomfördes i databaserna Medline via PubMed och Academic Search Elite utifrån i förväg uppsatta kriterier. Totalt 19 artiklar granskades och inkluderades i studien. Huvudresultatet visade att moral distress existerar och är frekvent inom vården och sjuksköterskeyrket. Av författarnas resultat framkommer att det tycks finnas flera faktorer av betydelse för utvecklingen av moral distress, som livsuppehållande vård, konkurrerande lojaliteter, konflikt med läkaren, kommunikationshinder, emotionella hinder, kulturella hinder, föreskrifter och regler och arbetsmiljöfaktorer ger sjuksköterskan svårlösta eller olösta etiska och moraliska dilemman. Konsekvenserna av detta kan bidra till långvariga stressrelaterade hälsoproblem, så som huvudvärk, smärta i nacke, muskler och mage, nedstämdhet, ilska, skuld och depression. Moral distress får även konsekvenser för professionen så som avståndstagande till patienter, anhöriga och arbetskamrater, motstånd att gå till jobbet och att utföra sina arbetsuppgifter. Författarna drar slutsatsen att följderna av moral distress inte bara drabbar sjuksköterskan utan onekligen även patienter, anhöriga och övriga i vårdkedjan.</p>

The aim of the present literature study was to describe the significant factors contributing to the development of moral distress and the consequences of moral distress can lead to in the nurse profession. A literature search was performed in the databases Medline through PubMed and Academic Search Elite on the basis of in advanced defined criterions. A total of 19 articles was reviewed and included in the study. The main result revealed that nurses experience moral distress and that it is frequent within the nurse profession. The findings revealed that there seem to be several significant factors in the development of moral distress, such as providing life-sustaining care, competing loyalties, conflicts with the physician, communication barriers, emotional barriers, cultural barriers, regulation and rules and working environment that gives the nurse difficult or unsolved ethical dilemmas. The consequences of moral distress can contribute to health problems both physical symptoms and mentally, such as headache, neck and muscle pain, stomach problems, depression, anger and guilt. Moral distress affects the nurse professionally, and contributes to distancing from patients, relatives and colleagues, a resistance against going to work and to perform work tasks. The conclusion is that the consequences of moral distress don’t just affect nurses but undeniably also patients, relatives and other instances in within the healthcare system. / Syftet med denna litteraturstudie var att beskriva de faktorer som har betydelse för utvecklingen av moral distress, och vilka konsekvenser moral distress kan leda till i sjuksköterskans yrkesutövning. En litteratursökning genomfördes i databaserna Medline via PubMed och Academic Search Elite utifrån i förväg uppsatta kriterier. Totalt 19 artiklar granskades och inkluderades i studien. Huvudresultatet visade att moral distress existerar och är frekvent inom vården och sjuksköterskeyrket. Av författarnas resultat framkommer att det tycks finnas flera faktorer av betydelse för utvecklingen av moral distress, som livsuppehållande vård, konkurrerande lojaliteter, konflikt med läkaren, kommunikationshinder, emotionella hinder, kulturella hinder, föreskrifter och regler och arbetsmiljöfaktorer ger sjuksköterskan svårlösta eller olösta etiska och moraliska dilemman. Konsekvenserna av detta kan bidra till långvariga stressrelaterade hälsoproblem, så som huvudvärk, smärta i nacke, muskler och mage, nedstämdhet, ilska, skuld och depression. Moral distress får även konsekvenser för professionen så som avståndstagande till patienter, anhöriga och arbetskamrater, motstånd att gå till jobbet och att utföra sina arbetsuppgifter. Författarna drar slutsatsen att följderna av moral distress inte bara drabbar sjuksköterskan utan onekligen även patienter, anhöriga och övriga i vårdkedjan.

Nurses experience stress, fear and anger while they are trying to reconcile their ideals/ goals about health care with its inadequacies and abuses (Jameton, 1984:5), while at the same time trying to stay true to their convictions (Lindh et al., 2010:552). Moral distress is experienced when nurses cannot adhere to these goals (Corley, 2002:637). Conflicting moral principles, stress-provoking and contradicting demands weaken the nurse’s sense of control, power and autonomy (Lützen et al., 2010:213). The current descriptions of moral distress inadequately define the concept, and this might lead to the inconsistent use of the term moral distress. Therefore, conceptual clarity is needed. Current available instruments measure antecedents and situations causing moral distress. Therefore, an instrument measuring the attributes of moral distress is urgently needed. Such an instrument might be used in a variety of clinical departments because it is not based on department-specific situations but on the attributes of moral distress. Moral distress has a great impact on the nurse, patient care and the organization. This research used Benson and Clark’s (1982) method of instrument development as a theoretical framework. It is the aim of this study to develop and validate an instrument to measure moral distress in the clinical health care context of the professional nurse. In order to attain this aim the following objectives were set: To conduct an integrative literature review to identify antecedents, consequences, attributes and empirical indicators of moral distress; to conduct interviews to explore professional nurses’ experience of moral distress; to develop an instrument to measure moral distress in professional nurses; to validate the instrument. A qualitative and quantitative research design with explorative, descriptive and contextual strategies was used. The research process was divided into phases. During Phase One, an integrative literature review was conducted and the population included all available national and international data on moral distress in nurses/ nursing and sampling included all-inclusive sampling. Data analysis was performed through descriptive synthesis.Phase Onealso included semi-structured interviews and the population included professional nurses working in hospitals and clinics in the North-West Province. The sampling method applied was purposive sampling. Tesch’s method was used as data analysis method. During Phase Two, a content validation was conducted and the population included experts in the field of moral distress and instrument validation, and purposive sampling was applied. Data collection was done through the instrument that was developedand data analysis was the content validity index. Phase Twoalso included a qualitative evaluation which was conducted and the population consisted of professional nurses working in hospitals and clinics in the North-West Province and purposive sampling was applied. Data was collected through the developed instrument and a focus group session. Data analysis was conducted through aconsensus discussion. During Phase Three, a pilot study was conducted and the population was professional nurses working ina hospital with different departments and clinics in the Free State Province. All-inclusive sampling was applied and the instrument that was developed was used as data collection. Data analysis included: Descriptive statistics, factor analysis (exploratory, confirmatory and Bartlett’s test of spherity), Cronbach’s alpha coefficient, correlations and ANOVA. According to the results from the face-, content-, exploratory and confirmatory, discriminant- as well as divergent validity, the instrument has been shown to be valid. The Cronbach’s alpha for the Moral Distress Instrument was deemed reliable. Finally, the research was evaluated and limitations were identified. Recommendations for nursing education, -practice, research and policy were formulated. / PhD (Nursing), North-West University, Potchefstroom Campus, 2014