Elizabeth G. Epstein

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.

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.

Racial Discrimination and Adverse Birth Outcomes: An Integrative Review

INTRODUCTION This article presents an integrative review of the literature examining the relationship between racial discrimination and adverse birth outcomes. METHODS Searches for research studies published from 2009 to 2015 were conducted using PubMed, CINAHL, Scopus, PsycINFO, Web of Science, and Embase. Articles were assessed for potential inclusion using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2009 framework. RESULTS Fifteen studies met criteria for review. The majority of the studies found a significant relationship between racial discrimination and low birth weight, preterm birth, and small for gestational age. Each of the studies that examined more proximal variables related to birth outcomes such as entry into prenatal care, employment opportunities, neighborhood characteristics, or inflammatory markers found significant associations between the specific variables examined and racial discrimination. Participants in qualitative studies discussed experiences of institutional racism with regard to several components of prenatal care including access and quality of care. DISCUSSION Racial discrimination is a significant risk factor for adverse birth outcomes. To best understand the mechanisms by which racial discrimination impacts birth outcomes, and to inform the development of effective interventions that eliminate its harmful effects on health, longitudinal research that incorporates comprehensive measures of racial discrimination is needed. Health care providers must fully acknowledge and address the psychosocial factors that impact health outcomes in minority racial/ethnic women.

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

What the “F”?

relate. When a crisis occurs and a child is seriously ill, parents often suffer an existential crisis themselves, reliving those milestone moments in their child’s life and questioning their parenting skills or decisions that were made, wondering what they could have done differently or why God would allow for such pain and suffering. Weiss and Fiester (2018) bring attention to the ethical challenges of pediatric care for seriously ill children, and broaden our thinking about ways to compassionately and respectfully incorporate parental preferences and goals into early and repeated discussions. This is no easy feat for the physicians, nurses, and parents who want to see positive outcomes. But, incorporating meaningful engagement of and connection with parents (Feudtner 2007; Janvier, Barrington, and Farlow 2014) is an important step in improving end-of-life communication and potentially limiting the trauma families experience in the loss of a child. Weiss and Fiester (2018) offer tools to help make this a reality. &

Human factors related to time-dependent infection control measures: “Scrub the hub” for venous catheters and feeding tubes

HighlightsKnowledge of existing infection control measures does not imply adherence, particularly when time‐based practices and time estimation are necessary aspects of the practice.Institution of timing devices is an effective tool in increasing adherence to time‐based–dependent practices.We demonstrated these findings for the hub care of both venous catheters and feeding tubes.Aids that qualify specific times to account for human factors should be implemented to ensure adherence to time‐dependent measures aimed at decreasing nosocomial infections. Background: The use of catheter hub decontamination protocols is a common practice to reduce central line–associated bloodstream infections. However, few data exist on the most effective disinfection procedure prior to hub access accounting for human factors and time‐dependent practices in real time in the clinical setting. Methods: An observational design with a multimodal intervention was used in this study in a neonatal intensive care unit. Direct observations on nurse compliance of scrub times with decontamination when accessing of venous catheter and feeding tube hubs were conducted during 3 phases: (1) baseline period prior to any interventions; (2) during an educational intervention phase; and (3) during a timer intervention period when using a timing device, either an actual timer or music button. Results: Overall, both education and the timing device interventions increased the mean scrub time ± SD of venous catheter hubs. Mean baseline scrub times of 10 ± 5 seconds were lower compared with 23 ± 12 seconds after educational intervention (P < .002) and 31 ± 8 seconds with timer or music button use (P < .001). Timer intervention scrub time was also more effective than education alone (P < .05). Similar findings were observed with scrub times of feeding tubes. Conclusions: Time‐based infection control measures, such as scrubbing the hub, must be implemented with aids that qualify specific times to account for human factors, to ensure adherence to time‐dependent measures aimed at decreasing nosocomial infections.