Moral distress is a state of concern or anxiety that occurs when there is a correct action to take but an individual's ability to take that action is constrained in some way. Nurses, especially those who work in intensive care units (ICUs), may struggle with moral distress due to feelings of futility when caring for end-of-life patients. The purpose of this 1-group pretest-posttest quasi-experimental study, guided by Lazarus's theory of stress, coping, and adaptation, was to determine whether End-of-Life Nursing Education Consortium (ELNEC) education reduces moral distress in ICU nurses caring for end-of-life patients. A revised Moral Distress Survey (MDS-R 2017) by Hamric was given before and after ELNEC education to determine whether ELNEC reduced ICU nurses' moral distress level in relation to providing end-of-life care. Participants were 56 ICU nurses recruited from several healthcare institutions in the northeastern United States. Dependent t-test results showed that there was a significant difference (p = .002) in the intensity and frequency of moral distress in ICU nurses before versus after participating in an ELNEC education program. Recommendations for future study include investigating the potential long-term effects of ELNEC education on moral distress, using a larger sample size, and including nurses who work in areas other than ICU. This study may contribute to the development of interventions to reduce moral distress in nurses to make them less likely to leave their employers, subject to lower levels of moral distress, and able to achieve greater emotional and physical well-being. In showing that providing nurses with additional education can decrease their moral distress, this study may promote decreased job turnover and increased physical well-being for nurses, as well as improved nursing care at the end of life which may affect positive social change.

Syfte: Att undersöka i vilka situationer moralisk stress förekom hos sjuksköterskor inom somatisk vård och hur uppfattningen av moralisk stress påverkades av sjuksköterskans ålder och erfarenhet.Bakgrund: Moralisk stress hos sjuksköterskor uppkommer när de vet vad som borde göras, men strukturella, organisatoriska eller ekonomiska faktorer utgör ett hinder för att utföra rätt handling. Effekter av detta kan leda till dålig självkänsla, depression eller att arbetsplatsen lämnas.Metod: En litteraturstudie med granskning och bearbetning av tio kvantitativa vetenskapliga artiklar genomfördes.Resultat: Sjuksköterskor upplevde moralisk stress i samarbete med andra professioner samt vid samarbete inom den egna professionen. Moralisk stress upplevdes vid meningslöst vårdande som till exempel ineffektiv vård när läkaren gav inkompetent vård. Även vid meningslöst livsuppehållande vård upplevdes moralisk stress. I vissa etiska situationer och vid besparingar som innefattade personalbrist och kostnadsbesparingar, uppstod även moralisk stress. Korrelationen mellan ålder och erfarenhet hade också betydelse för nivån av moralisk stress.Konklusion: Det fanns flertalet situationer i vilka sjuksköterskor upplevde moralisk stress. Då vården i dagens samhälle ska bedrivas så kostnadseffektivt som möjligt påverkade detta sjukhusmiljön negativt, vilket resulterade i moralisk stress. Genom att bli uppmärksam på de situationer då det upplevs mest moralisk stress kan förebyggande arbete på sikt minska den moraliska stressen. / Objective: To investigate the situations in which moral distress occurred in nurses in somatic care and how the perception of moral distress was influenced by the nurse's age and experience.Background: Moral distress among nurses arise when they know what should be done, but structural, organizational or exclusive economic factors are an obstacle to perform the right action. The effects of this can lead to poor self-esteem, depression, or leaving work.Method: A literature review by reviewing and processing ten quantitative scientific articles was conducted.Results: Nurses experienced moral distress in collaboration with other professions and cooperation within the profession. At futile care, which included, for example ineffective care where the doctor gave incompetent care, as well as in life support care perceived moral distress. Even in some ethical situations and savings that included staff shortages and cost savings, moral distress occured. The correlation between age and experience were also significant for the level of moral distress.Conclusion: There were several situations in which nurses experienced moral distress. The hospital care in today's society is to be conducted as cost effectively as possible, this affected the hospital environment adversely, resulting in moral distress. By becoming attentive to those situations in which the most moral distress is experienced, prevention may eventually reduce moral distress.

Bakgrund: Att arbeta som sjuksköterska i palliativ vård innebär bland annat teamarbete, stöd till närstående och symtomlindring till patienter - i en miljö där arbetsbelastning många gånger är hög. Att möta etiskt svåra situationer och tvingas handla emot sina värderingar kan leda till samvetsstress. Syfte: Syftet var att beskriva sjuksköterskors upplevelser av samvetsstress inom palliativ vård. Metod: En kvalitativ litteraturöversikt gjordes, där totalt 16 kvalitativa artiklar ingick. Artiklarna hittades i databaserna PubMed, Cinahl Complete och PsycInfo, där relevanta sökord användes. Artiklarna kvalitetsgranskades, sammanställdes och analyserades utifrån Bettany-Saltikov och McSherrys metod för tematisk analys. Resultat: Tre huvudteman identifierades: Sjuksköterskan som person och yrkesroll, Sjuksköterskan i relation till patient och närstående samt Sjuksköterskan i relation till team och organisation. Tolv underteman framkom, där negativa känslor och konsekvenser av samvetsstress var framträdande. Likaså när sjuksköterskan handlade emot sina värderingar och oroade sig för misstag. Att inte handla enligt patientens önskemål och att vara oenig med närstående var relaterat till samvetsstress, likaså att bevittna lidande hos patient och närstående samt när sista tiden blev ovärdig eller meningslös. Bristfällig kommunikation, både med kollegor och med patient och närstående var relaterat till samvetsstress. Likaså brist på kompetens och resurser. Samvetsstress kunde också innebära positiva konsekvenser som självreflektion då sjuksköterskan kom till nya insikter. Slutsats: En ökad medvetenhet om vilka faktorer som kan ha samband med samvetsstress motiverar till utveckling av den palliativa vården där personcentrerad vård med god symtomlindring, god kommunikation, bra teamarbete och stöd till närstående är centrala delar. Detta borde kunna leda till att minska de negativa effekterna av samvetsstress hos sjuksköterskan och leda till en bättre palliativ vård för både patient och närstående. / Background: Working as a nurse in palliative care settings involves, for instance, team work, support for loved ones and symptom relief for patients - this in an environment where the workload is mostly high. Facing ethically difficult situations and being forced to act againstone’s values may result in moral distress. Aim: The purpose of this literature review was to describe palliative care nurses experiences of moral distress. Method: A qualitative literature review was made, which included a total of 16 qualitative articles. The articles were found in the databases PubMed, Cinahl Complete and PsycInfo, where relevant keywords were used. The articles were quality reviewed, compiled and were analyzed based on Bettany-Saltikov and McSherry's method for thematic analysis. Results: Three main themes were identified: The nurse as a person and professional role, The nurse in relation to the patient and relatives and The nurse in relation to the team and organization. Twelve sub-themes emerged, where negative feelings and consequences of moral distress were prominent. Likewise when the nurse acted against her values and worried about mistakes. Not acting according to the patient's wishes and disagreeing with relativeswas related to moral distress, as well as witnessing suffering in the patient and relatives and when the end-of-life became unworthy or futile. Inadequate communication, both with colleagues and with patients and relatives was related to moral distress. Likewise, lack of skills and resources. Moral distress could also have positive consequences such as selfreflection when the nurse came to new insights. Conclusion: An increased awareness of the factors that may be associated with the experience of moral distress motivates the development of palliative care where personcentered care with good symptom relief, good communication, good teamwork and support for relatives are central elements. This should lead to a reduction in the negative effects of moral distress on the nurse and lead to better palliative care for both patients and relatives.

Background: Nurses working in intensive care units are at high risk for experiencing moral distress, a response to an ethical event, in which a nurse recognizes or partakes in an action that does not align with their values. In response, nurses may experience negative health effects, which drives attrition. This can negatively impact patient care and the stability of healthcare organizations. There is a scarcity of high-quality and effective organizational interventions to mitigate moral distress, and even lesser work has been done to understand nurses’ practice-based needs to ameliorate moral distress. New conditions of moral distress in the context of COVID-19 have increased the relevance of these shortcomings. Aim: The purpose of this study was to learn about intensive care unit nurses’ responses to moral distress experienced in their professional practice during the COVID-19 pandemic. Methods: This interpretive descriptive study explored the experiences of 40 intensive care unit nurses, who self-reported experiencing moral distress in their professional practice during the COVID-19 pandemic (March 2020 – Sept 2021). Data generation included a demographic questionnaire, including the Measure of Moral Distress - Healthcare Professionals survey, and one-to-one semi-structured virtual interviews. The categorization and synthesis of the data was guided by methods of reflexive thematic analysis and rapid qualitative analysis. Results: Findings indicated that nurses regularly navigated pre-existing and novel ethical events in practice, which were exacerbated in the context of the COVID-19 pandemic. In response, they often experienced moral distress under the complex interplay of two overarching and broad conditions: (1) when nurses’ voices were not heard; and (2) when patients received substandard levels of care, that was not patient-centered, pain free, or that did not align standards of care. Moral distress experienced by nurses resulted in negative outcomes across serval health domains, that drove feelings of burnout and attrition. To cope, nurses engaged in patterns of action, avoidance, and acquiesce. Finally, they made recommendations for mitigative interventions rooted in their desire to be heard, in efforts to optimize patient care and nurse well-being. Conclusion: Intensive care unit nurses’ voices need to be amplified and valued, in the context of various healthcare organizations (e.g., practice, research, education and polity), to mitigate moral distress and the associated negative outcomes. / Thesis / Master of Health Sciences (MSc)

As a healthcare professional at the bedside, it has been very difficult to advocate for the patient while all parties involved cannot respect what the patient wants. Four out of five Americans do not have an advance directive. The history and court cases that have led the country to make patient’s right to make their own healthcare decisions has been decades in the making, yet still bring daily challenges within the healthcare system. When a patient’s wishes are not being honored, medical futility may lead to moral distress and compassion fatigue. Institutions provide multidisciplinary teams to address these issues, but if a patient’s capacity or competence is in question, their voice may not be heard. The toll on the healthcare provider and the patient can be permanently damaging, causing many nurses to leave the profession all together. I will attempt to determine the barriers to implementing the patient’s wishes, address the syndrome of moral distress among healthcare professionals, and attempt to offer solutions to promote well rounded, patient-centered care. / Urban Bioethics

O sofrimento moral é descrito na literatura como o sentimento resultante do impedimento à uma ação considerada moralmente apropriada, devido, sobretudo, a obstáculos institucionais, como a falta de recursos e a carga de trabalho. As consequências envolvem sintomas físicos, como mal estar, choro e desordens do sono e sintomas psicológicos, como frustração, impotência e culpa, além de implicações organizacionais, principalmente relacionadas com afastamentos e abandono do emprego. Considerando que o contexto de trabalho pode influenciar na vivência de situações moralmente problemáticas, o objetivo do estudo foi analisar o fenômeno do sofrimento moral em enfermeiros no Brasil e em Portugal. Trata-se de uma pesquisa metodológica para desenvolvimento, busca de evidências de validade e refinamento de um instrumento de pesquisa. A investigação partiu da análise de 38 estudos da literatura para construção de uma escala para identificação de fatores de risco para sofrimento moral. A busca por evidências de validade incluiu uma análise de juízes, para validação de conteúdo, e uma análise fatorial exploratória, para validação de constructo, com uma amostra de 268 enfermeiros brasileiros e 278 enfermeiros portugueses. O resultado foi uma escala com evidência de validade para ambos os países, com Alpha de Cronbach de 0,913 e 0,790, teste de Kaiser-Meyer Olkin de 0,869 e 0,914 e índice de Bartlett significativo (p <0,001) para Brasil e Portugal, respectivamente. Cerca de 59,8% da variância é explicada por 30 itens, divididos em sete fatores, na versão brasileira, e cerca de 53,9% da variância é explicada por 20 itens, divididos em 4 fatores, na versão portuguesa. A vivência de fatores de risco para sofrimento moral foi considerada moderada no Brasil e baixa em Portugal. As variáveis que mostraram associação significativa com maiores médias totais de risco nos dois países foram o tipo de serviço, as horas de trabalho, estar em sofrimento moral e ter a intenção de deixar o emprego atual. Pesquisas no âmbito do sofrimento moral podem, entre outros aspectos, auxiliar na identificação dos desafios e das dificuldades que mais preocupam os enfermeiros em seu contexto de trabalho. No intuito de contribuir no desenvolvimento de estratégias de enfrentamento e melhorar a retenção e a satisfação profissional, pesquisas acerca do sofrimento moral podem refletir positivamente na qualidade dos cuidados. / Moral distress is described as the feeling resulting from the impediment to an action considered morally appropriate, mainly due to institutional obstacles such as the lack of resources and the high workload. Main consequences are physical symptoms, such as malaise, crying and sleep disorders and psychological symptoms, such as frustration, impotence and guilt, as well as organizational implications, mainly related to withdrawal and abandonment of employment. Considering that the work context may influence the experience of morally problematic situations, the objective of these study was to analyze the phenomenon of moral distress among nurses in Brazil and in Portugal. It is a methodological research for development, searching for evidence of validity and refinement of a research instrument. The research started with the analysis of 38 studies for the construction of a scale to identify risk factors for moral distress. The search for evidence of validity included an analysis of judges, for content validation, and an exploratory factorial analysis, for construct validation, with a sample of 268 Brazilian nurses and 278 Portuguese nurses. The result was a scale with evidence of validity, Cronbachs Alpha of 0,913 and 0,790, Kaiser-Meyer Olkin test of 0,869 and 0,914 and a significant Bartlett (p <0,001). About 59,8% of the variance was explained by 30 items, divided into seven factors in the Brazilian version, and about 53,9% of the variance was explained by 20 items, divided into four factors in the Portuguese version. The experience of risk factors for moral distress was considered moderate in Brazil and low in Portugal. The variables that showed a significant association with the highest risk for moral distress in both countries were the type of work context, the hours of work, being in moral distress and having the intention to leave the current job. Research in the field of moral distress can, among other things, help in identifying the challenges and difficulties that most concern nurses in their work context. In order to contribute to the development of coping strategies and to improve professional retention and satisfaction, researches about moral distress may positively reflect on the quality of care.

<p>Ongoing structural and financial changes in the health care sector have resulted in increased risks for ethical dilemmas and moral distress. It is purported that increased ethical competence will help staff manage ethical dilemmas and hence decrease moral distress. To enhance ethical competence several approaches may be used – theoretical education, and methods focusing on reflection and decision-making abilities.</p><p>Ethics rounds are a widespread systematic method hypothesized to improve ethical competence, nurture a reflective climate, and help in ethical decision-making. Despite its popularity, its effects on moral distress have hitherto never been evaluated in a controlled study.</p><p>The purpose of this thesis was to evaluate the impact of an intervention, including ethics rounds; the hypothesis being that the intervention would decrease perceived moral distress. An additional aim was exploring the concept of moral distress in various health care establishments, including pharmacies.</p><p>Focus groups were conducted to explore the concept of moral distress. To evaluate the intervention a scale assessing staff-perceived moral distress was designed, validated, and implemented.</p><p>Results showed that moral distress is evident in diverse health care settings. Some factors associated with this were lack of resources, conflicts of interest, and rules that are incompatible with practice. An expanded definition of moral distress was presented.</p><p>The training program was much appreciated by participants. However, no significant effects on perceived moral distress were found. Reasons could be that the intervention was too short or otherwise ineffective, there is no association between ethical competence and moral distress, the assessment scale was not sensitive enough, or management was not sufficiently involved.</p><p>There is a need to further refine the various aspects of ethical dilemmas in clinical settings, and to evaluate the most efficient means to enhance skills for dealing with ethical dilemmas, for the benefit of staff, patients, institutions, and society.</p>

Ongoing structural and financial changes in the health care sector have resulted in increased risks for ethical dilemmas and moral distress. It is purported that increased ethical competence will help staff manage ethical dilemmas and hence decrease moral distress. To enhance ethical competence several approaches may be used – theoretical education, and methods focusing on reflection and decision-making abilities. Ethics rounds are a widespread systematic method hypothesized to improve ethical competence, nurture a reflective climate, and help in ethical decision-making. Despite its popularity, its effects on moral distress have hitherto never been evaluated in a controlled study. The purpose of this thesis was to evaluate the impact of an intervention, including ethics rounds; the hypothesis being that the intervention would decrease perceived moral distress. An additional aim was exploring the concept of moral distress in various health care establishments, including pharmacies. Focus groups were conducted to explore the concept of moral distress. To evaluate the intervention a scale assessing staff-perceived moral distress was designed, validated, and implemented. Results showed that moral distress is evident in diverse health care settings. Some factors associated with this were lack of resources, conflicts of interest, and rules that are incompatible with practice. An expanded definition of moral distress was presented. The training program was much appreciated by participants. However, no significant effects on perceived moral distress were found. Reasons could be that the intervention was too short or otherwise ineffective, there is no association between ethical competence and moral distress, the assessment scale was not sensitive enough, or management was not sufficiently involved. There is a need to further refine the various aspects of ethical dilemmas in clinical settings, and to evaluate the most efficient means to enhance skills for dealing with ethical dilemmas, for the benefit of staff, patients, institutions, and society.

Bakgrund: Sjuksköterskor skattar sig att bli stressade av tidsbrist och resursbrist. Moralisk stress uppstår ur dilemman. Dilemmat uppstår när det finns begränsningar i organisationen, konflikter med bedömningar som andra har gjort hindrar en att göra det som egentligen anses riktigt och tankar uppkommer om vad som ska göras istället.   Syfte: Att undersöka distriktssköterskans erfarenhet av stress i sitt arbete på vårdcentral med fokus på moralisk stress.   Metod: En kvalitativ studie med semistrukturerade intervjuer har genomförts med åtta distriktssköterskor och analyserades med manifest kvalitativ innehållsanalys.   Resultat: Distriktssköterskorna erfor stress i många olika situationer och det som var mest framträdande var tidsbrist samt situationer i telefonrådgivningen. Det fanns ett större vårdbehov än vad det fanns läkartider och då kunde inte distriktssköterskorna ge den vård som de önskade. Regler och rutiner kunde upplevas som hindrande i mötet med patienten vilket gav uttryck som frustation och tankar om vad som var rätt att göra.   Slutsats: Distriktssköterskorna upplever stress, oro och frustration vid stor vårdtyngd, lite personal, brist på läkartider och när kommunikationen mellan kollegor och patienter brister. Distriktssköterskorna står inför dilemman på grund av att regler och rutiner i organisationen hindrar dem att utföra den vård de önskar vilket visar på att de erfar moralisk stress. / Background: Nurses think themselves to be stressed by time constraints and lack of resources. Moral distress arise out of dilemmas and these dilemmas emerge when there are limitations in the organization and conflicts between previous assessments and, contradicting thoughts about what can be done instead arise.   Purpose: To examine the district nurse's experience of stress in their work on health center, focusing on moral distress.   Method: A qualitative study with semi-structured interviews was conducted with eight district nurses and to analyze, manifest content analysis was used.   Results: The district nurse´s experience stress in many different situations, lack of time and struggles with telephone counseling was the most prominent. The need for care is greater than there are doctor’s appointments and the district nurses cannot provide the care they desire. When meeting with patients, rules and procedures can be more obstructive than helpful, this often led to feelings of frustration and second guessing the right thing to do.   Conclusion: District nurses experience stress, concern and frustration when there is too much workload, staff shortages, when times for doctors’ appointments are few and the communication between colleagues and patients is insufficient. The district nurses are facing these dilemmas because the rules and procedures in the organization prevent them from performing the care they desire. In other words, they are experiencing moral distress.

Fundação de Amparo a Pesquisa no Estado do Rio Grande do Sul / Introduction: Pediatric nursing practice is becoming increasingly complex, since the profile of Brazilian children is in the process of change, bringing the increase in the number of children with special health care needs. Nurses are professionals with an important knowledge about the best interests of children and families, advocating on behalf of their welfare and are thus inclined to experience moral distress. Aim: The aim of this study was to examine the experiences of moral distress of nurses who care for children with special healthcare needs. Methodology: interpretive phenomenology was selected as the study method. Nine nurses working at three different pediatric units of a teaching hospital were interview in November and December 2014. The data analysis process was held according to Patricia Benner's framework. The process consisted of transcription, coding, thematic analysis, and search for paradigm cases and exemplars. All the ethical aspects were preserved and the study was approved by the Research Ethics Committee of the institution under number 36618114.4.0000.5346. Results: Data analysis identified three themes. The themes arises from the relationships that nurses experienced in their daily lives and therefore their different moral experiences. Their moral experiences can be changed by their engagements. The nurses of this study are engaged in different levels according to their concerns throughout pediatrics nursing practice. Depending on the relationship they are living; with the health team, with other nurses, with the child's family, and the child; the participants can experience distress, anguish, frustration, satisfaction, responsibility. Conclusion: The findings identified that the engagement of nurses can be modified all the time during childcare situations and can instigate or inhibit their moral agency, according to their understanding of the nursing practice. / Introdução: A prática da enfermagem em pediatria vem se tornando cada vez mais complexa, uma vez que o perfil da infância brasileira encontra-se em processo de mudança, trazendo consigo o aumento do número de crianças com necessidades especiais de saúde. Os enfermeiros constituem-se em profissionais com importante conhecimento acerca dos melhores interesses da criança e da família, advogando em prol de seu bem estar, estando, dessa forma, inclinado a vivenciar o sofrimento moral. Objetivo: compreender como o sofrimento moral se apresenta no cotidiano de cuidado de enfermeiros que cuidam de crianças com necessidades especiais de saúde. Metodologia: Estudo fenomenológico interpretativo, realizado em três unidades de internação pediátrica e neonatal de um hospital de ensino. Participaram do estudo nove enfermeiros e a coleta dos dados foi realizada por meio de entrevista nos meses de novembro e dezembro de 2014. As entrevistas foram gravadas e transcritas. A análise deste estudo foi feita a partir da perspectiva Fenomenológica Interpretativa de Patrícia Benner. Na análise interpretativa ocorreu a busca por exemplares e casos paradigmáticos e na análise temática elencou-se os padrões de significado que possibilitaram a compreensão do fenômeno. Assim, três temas foram descritos referente às relações das enfermeiras que culminam no aparecimento de vivências morais. O estudo preservou os princípios éticos da pesquisa, conforme Resolução Nº 466, de 12 de dezembro de 2012 e foi aprovado pelo Comitê de Ética em Pesquisa da instituição, sob número 36618114.4.0000.5346. Resultados: As enfermeiras deste estudo mostraram-se engajadas em diversos níveis de intensidade diante das preocupações relacionados ao cuidado em pediatria. Dessa forma, na relação com a equipe de saúde, com os enfermeiros, com a família da criança, e com a criança, as participantes vivenciaram um cuidado que gera sofrimento, angústia, sentimento de frustração, satisfação, responsabilidade, entre outros. Conclusão: concluiu-se que o engajamento das enfermeiras modifica-se a todo o momento nas situações de cuidado à criança, podendo instigar a sua agência moral ou inibindoa, de acordo com as compreensões sobre a prática de enfermagem.