Ann B. Hamric

Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals

Background: Although moral distress is increasingly recognized as an important problem that threatens the integrity of health care providers and health care systems, few reliable and valid measures of moral distress are currently in use in research or clinical practice. This article describes the development and testing of a revised measure of moral distress, the Moral Distress Scale–Revised (MDS-R), designed for use in multiple health care settings and with multiple disciplines. Methods: After instrument development and content validity testing, a survey methodology was used to assess reliability and construct validity of the MDS-R. Registered nurses (n = 169) and physicians (n = 37) in eight intensive care units (ICUs) at an academic medical center in the southeastern United States participated; the survey was administered during a 2-week period in January 2011. Results: Adequate reliability and evidence of construct validity were demonstrated. Moral distress was significantly higher for nurses than physicians, although it was negatively correlated with ethical climate for both provider groups. MDS-R scores were significantly higher for those clinicians considering leaving their positions. The proportion of physicians and nurses who had left a previous position or who were considering leaving their current positions due to moral distress was high (16% and 31%, respectively). Conclusions: Initial testing of the MDS-R reveals promising evidence of instrument reliability and validity. The findings from this study lend further support to the important relationships between the moral distress of providers, the ethical climate of health care settings, and retention of health care professionals.

Empirical Research on Moral Distress: Issues, Challenges, and Opportunities

Studying a concept as complex as moral distress is an ongoing challenge for those engaged in empirical ethics research. Qualitative studies of nurses have illuminated the experience of moral distress and widened the contours of the concept, particularly in the area of root causes. This work has led to the current understanding that moral distress can arise from clinical situations, factors internal to the individual professional, and factors present in unit cultures, the institution, and the larger health care environment. Corley et al. (2001) was the first to publish a quantitative measure of moral distress, and her scale has been adapted for use by others, including studies of other disciplines (Hamric and Blackhall 2007; Schwenzer and Wang 2006). Other scholars have proposed variations on Jameton’s core definition (Sporrong et al. 2006, 2007), developing measures for related concepts such as moral sensitivity (Lutzen et al. 2006), ethics stress (Raines 2000), and stress of conscience (Glasberg et al. 2006). The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it. Increased attention by researchers in disciplines other than nursing has taken different forms, some problematic. Cultural differences in the role of the nurse and understanding of actions that represent threats to moral integrity also challenge efforts to build a cohesive research-based understanding of the concept. In this paper, research efforts to date are reviewed. The importance of capturing root causes of moral distress in instruments, particularly those at unit and system levels, to allow for interventions to be appropriately targeted is highlighted. In addition, the issue of studying moral distress and interaction over time with moral residue is discussed. Promising recent work is described along with the potential these approaches open for research that can lead to interventions to decrease moral distress. Finally, opportunities for future research and study are identified, and recommendations for moving the research agenda forward are offered.

Moral Distress Among Healthcare Professionals: Report of an Institution‐Wide Survey

PURPOSE Moral distress is a phenomenon affecting many professionals across healthcare settings. Few studies have used a standard measure of moral distress to assess and compare differences among professions and settings. DESIGN A descriptive, comparative design was used to study moral distress among all healthcare professionals and all settings at one large healthcare system in January 2011. METHODS Data were gathered via a web-based survey of demographics, the Moral Distress Scale-Revised (MDS-R), and a shortened version of Olsons Hospital Ethical Climate Scale (HECS-S). FINDINGS Five hundred ninety-two (592) clinicians completed usable surveys (22%). Moral distress was present in all professional groups. Nurses and other professionals involved in direct patient care had significantly higher moral distress than physicians (p = .001) and other indirect care professionals (p < .001). Moral distress was negatively correlated with ethical workplace climate (r = -0.516; p < .001). Watching patient care suffer due to lack of continuity and poor communication were the highest-ranked sources of moral distress for all professional groups, but the groups varied in other identified sources. Providers working in adult or intensive care unit (ICU) settings had higher levels of moral distress than did clinicians in pediatric or non-ICU settings (p < .001). Providers who left or considered leaving a position had significantly higher moral distress levels than those who never considered leaving (p < .001). Providers who had training in end-of-life care had higher average levels of moral distress than those without this training (p = .005). CONCLUSIONS Although there may be differences in perspectives and experiences, moral distress is a common experience for clinicians, regardless of profession. CLINICAL RELEVANCE Moral distress is associated with burnout and intention to leave a position. By understanding its root causes, interventions can be tailored to minimize moral distress with the ultimate goal of enhancing patient care, staff satisfaction, and retention.

Reflections on the continuing evolution of advanced practice nursing

While the concept of advanced practice nursing (APN) is still relatively new, distinct patterns of evolution from specialty practice to advanced practice nursing are evident over the last 100 years. The purpose of this article is to describe 3 stages in this evolutionary process, as well as discuss several internal and external issues that represent challenges facing APN educators and clinicians who seek to strengthen advanced practice in the current healthcare system. We clarify our definition of advanced practice nursing, and note the critical need for cohesion within the profession regarding the definition and core competencies of advanced practice. Our aim is to suggest a preferred vision for advanced credentialing. We encourage dialogue among our nursing colleagues to move this agenda forward.

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

PURPOSE To determine which demographic characteristics are associated with moral distress in intensive care unit (ICU) professionals. METHODS We distributed a self-administered, validated survey to measure moral distress to all clinical personnel in 13 ICUs in British Columbia, Canada. Each respondent to the survey also reported their age, sex, and years of experience in the ICU where they were working. We used multivariate, hierarchical regression to analyze relationships between demographic characteristics and moral distress scores, and to analyze the relationship between moral distress and tendency to leave the workplace. RESULTS Response rates to the surveys were the following: nurses--428/870 (49%); other health professionals (not nurses or physicians)--211/452 (47%); physicians--30/68 (44%). Nurses and other health professionals had higher moral distress scores than physicians. Highest ranked items associated with moral distress were related to cost constraints and end-of-life controversies. Multivariate analyses showed that age is inversely associated with moral distress, but only in other health professionals (rate ratio [95% confidence interval]: -7.3 [-13.4, -1.2]); years of experience is directly associated with moral distress, but only in nurses (rate ratio (95% confidence interval):10.8 [2.6, 18.9]). The moral distress score is directly related to the tendency to leave the ICU job, in both the past and present, but only for nurses and other non-physician health professionals. CONCLUSION Moral distress is higher in ICU nurses and other non-physician professionals than in physicians, is lower with older age for other non-physician professionals but greater with more years of experience in nurses, and is associated with tendency to leave the job.

Must We Be Courageous

Courage is indispensable. Telling caregivers they must be courageous in difficult circumstances is sometimes a back-handed endorsement of oppression, however.

The nurse as a moral agent in modern health care

Edi tor s n o t e : I am pleased to introduce a new column dedicated to ethical issues that confront nurses and nursing. Nursing Outlook is indeed fortunate to have secured Ann Hamric to author this column. She brings a wealth of knowledge, experience, and keen insight into these issues. We are hoping that this column provokes discussion and debate among our readers--certainly this inaugural topic should provoke your thinking about this important issue. We welcome your comments.

A Health System-wide Moral Distress Consultation Service: Development and Evaluation

Although moral distress is now a well-recognized phenomenon among all of the healthcare professions, few evidence-based strategies have been published to address it. In morally distressing situations, the “presenting problem” may be a particular patient situation, but most often signals a deeper unit- or system-centered issue. This article describes one institution’s ongoing effort to address moral distress in its providers. We discuss the development and evaluation of the Moral Distress Consultation Service, an interprofessional, unit/system-oriented approach to addressing and ameliorating moral distress.

Is Broader Better

In their article “A Broader Understanding of Moral Distress,” Campbell, Ulrich, and Grady (2016) correctly assert that moral distress is well established in the nursing literature and is gaining attention in other health care professions. These are significant points. For decades, moral distress simmered quietly in the health care professions—unstudied, unacknowledged, and insidiously damaging careers. Today, the phenomenon is finally receiving the attention it deserves at the bedside, in institutional boardrooms, in the classroom, and on research priority lists. As the authors state, “Moral distress is, first and foremost, a practical problem.” The current understanding of moral distress has identifiable boundaries, and, while not perfect, has utility in practice and evolving research. We argue that the authors’ broader definition of moral distress dilutes the concept to such a degree as to render it impractical—too nebulous to be effectively taught, studied, used in practice, or, frankly, respected any longer as a powerful phenomenon in bioethics. The authors are not the first to attempt to redefine moral distress. At least 13 previous articles have offered new definitions since Jameton first coined the term in the 1980s (e.g., Hamric 2014; McCarthy and Deady 2008; Thomas and McCullough 2015; Varcoe et al. 2012). Nearly all of the earlier attempts have maintained the same core element: being compelled to act in a way that one believes is morally wrong but feels powerless to change. Campbell, Ulrich, and Grady move away from this central understanding into

Reflections on Moral Distress and Moral Success

This final chapter captures the voices of several leaders in health care and bioethics who responded to one or both of the following questions: 1. What do you think is the most significant or important reason that healthcare professionals might feel trapped and unable to do what they think is right (and hence experience moral distress)? 2. What does moral success look like to you? Can you give an example of moral success from your perspective with regard to healthcare?