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

AIMS: The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.BACKGROUND: 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 phenomenon.DESIGN: Systematic literature review and narrative synthesis (November 2015-March 2016).DATA SOURCES: Ovid MEDLINE®In-Process &amp; 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 Abstracts.REVIEW METHODS: Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.RESULTS: In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.CONCLUSION: We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.</p

A model to advance nursing science in trauma practice and injury outcomes research

Aims: This paper presents a model to advance nursing science and practice in trauma care. Background: The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Data Sources: Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990 – 2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken. Discussion: Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long term outcomes. Implications for Policy and Practice: This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice. Conclusion: Planning and integrating care across the trauma continuum, as well as recognition of the role of the injured person’s background, family and resources, will lead to improved long term outcomes

Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.Published versio

Advancement of the German version of the moral distress scale for acute care nurses : a mixed methods study

Aim: Moral distress experienced by nurses in acute care hospitals can adversely impact the affected nurses, their patients and their hospitals; therefore, it is advisable for organizations to establish internal monitoring of moral distress. However, until now, no suitable questionnaire has been available for use in German‐speaking contexts. Hence, the aim of this study was to develop and psychometrically test a German‐language version of the Moral Distress Scale. Design: We chose a sequential explanatory mixed methods design, followed by a second quantitative cross‐sectional survey. Methods: An American moral distress scale was chosen, translated, culturally adapted, tested in a pilot study and subsequently used in 2011 to conduct an initial web‐based quantitative cross‐sectional survey of nurses in all inpatient units at five hospitals in Switzerland's German‐speaking region. Data were analysed descriptively and via a Rasch analysis. In 2012, four focus group interviews were conducted with 26 nurses and then evaluated using knowledge maps. The results were used to improve the questionnaire. In 2015, using the revised German‐language instrument, a second survey and Rasch analysis were conducted. Results: The descriptive results of the first survey's participants (n = 2153; response rate: 44%) indicated that moral distress is a salient phenomenon in Switzerland. The data from the focus group interviews and the Rasch analysis produced information valuable for the questionnaire's further development. Alongside the data from the second survey's participants (n = 1965; response rate: 40%), the Rasch analysis confirmed the elimination of previous deficiencies on its psychometrics. A Rasch‐scaled German version of the Moral Distress Scale is now available for use

Family presence during resuscitation: a narrative review of the practices and views of critical care nurses

Background The option of family presence during resuscitation was first presented in the late 1980s. Discussion and debate about the pros and cons of this practice has led to an abundant body of international research. Aim To determine critical care nurses’ experiences of, and support for family presence during adult and paediatric resuscitation and their views on the positive and negative effects of this practice. Methods A narrative literature review of primary research published 2005 onwards. The search strategy comprised an electronic search of three bibliographic databases, supplemented by exploration of a web-based search engine and hand-searching. Results Twelve studies formed the review. Research primarily originated from Europe. The findings were obtained from a moderately small number of nurses, and their views were mostly based on conjecture. Among the factors influencing family presence during resuscitation were dominant concerns about harmful effects. There was a noticeable absence of compliance with recommended guidelines for practice, and the provision of a unit protocol or policy to assist decision-making. Conclusion A commitment to family-centred care, educational intervention and the uptake of professional guidance are recommended evidence-informed strategies to enhance nurses’ support for this practice in critical care.Published versio

Working relationships between obstetric care staff and their managers: a critical incident analysis

Background Malawi continues to experience critical shortages of key health technical cadres that can adequately respond to Malawi’s disease burden. Difficult working conditions contribute to low morale and frustration among health care workers. We aimed to understand how obstetric care staff perceive their working relationships with managers. Methods A qualitative exploratory study was conducted in health facilities in Malawi between October and December 2008. Critical Incident Analysis interviews were done in government district hospitals, faith-based health facilities, and a sample of health centres’ providing emergency obstetric care. A total of 84 service providers were interviewed. Data were analyzed using NVivo 8 software. Results Poor leadership styles affected working relationships between obstetric care staff and their managers. Main concerns were managers’ lack of support for staff welfare and staff performance, lack of mentorship for new staff and junior colleagues, as well as inadequate supportive supervision. All this led to frustrations, diminished motivation, lack of interest in their job and withdrawal from work, including staff seriously considering leaving their post. Conclusions Positive working relationships between obstetric care staff and their managers are essential for promoting staff motivation and positive work performance. However, this study revealed that staff were demotivated and undermined by transactional leadership styles and behavior, evidenced by management by exception and lack of feedback or recognition. A shift to transformational leadership in nurse-manager relationships is essential to establish good working relationships with staff. Improved providers’ job satisfaction and staff retentionare crucial to the provision of high quality care and will also ensure efficiency in health care delivery in Malawi