Leslie Rittenmeyer

How Professional Nurses Working in Hospital Environments Experience Moral Distress: A Systematic Review

BACKGROUND Jameton who first conceptualized moral distress, described it as arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. The phenomenon of moral distress is well documented in the nursing literature but no systematic review exists. The plethora of literature on moral distress would suggest that attention to this phenomenon is deemed noteworthy by the profession. A synthesized understanding of how nurses experience the phenomenon of moral distress is presented. OBJECTIVES The overall objective of this review was to appraise and synthesize the best available evidence on how professional nurses working in hospital environments experience ethical/moral distress. INCLUSION CRITERIA This review considered qualitative research including descriptive/exploratory studies whose participants were professional nurses working in hospital environments and experienced either moral or ethical distress as a result of their patient care responsibilities. Studies were included that described participants own experience of moral distress. SEARCH STRATEGY The search strategy sought to find both published and unpublished research studies. This review was limited to papers in English. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. METHODOLOGICAL QUALITY Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third party reviewer. DATA COLLECTION Information was extracted by two reviewers from each paper using the Qualitative Assessment and Review data extraction tool (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. DATA SYNTHESIS Data synthesis aimed to portray an accurate interpretation and synthesis of themes arising from the selected participants experience of moral distress. RESULTS A total of 50 studies were identified and of those 39 were included in the review. These qualitative studies examined how professional nurses working in hospital environments experienced moral/ethical distress. Findings were analyzed using the JBI-QARI tool. The process of meta-synthesis using this program involved categorizing findings and developing synthesized topics from the categories. Four syntheses were developed related to the experience of moral distress: human reactivity, institutional culpability, patient pain and suffering, and unequal power hierarchies. CONCLUSION Nurses who experience moral distress respond with a myriad of biological, psychological and stress reactions. Moral distress is experienced when nurses feel the need to advocate for patients well-being, while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions of which the nurse has little power to influence also contributed to the experience. Unequal power structure prevalent in institutions exacerbates the problem. IMPLICATIONS FOR PRACTICE In order to mitigate the effects of moral distress institutions need to design structures of support for nurses that provide education on the effects of moral distress, give nurses authentic voice in expressing ethical concerns and allow them to practice nursing in a way that does not violate their core professional values. IMPLICATIONS FOR RESEARCH Further research is needed on the effectiveness of interventions designed to decrease the effect of moral distress on the workplace environment. Additionally, measuring the effectiveness of strategies designed to provide nurses a platform to openly express their ethical concerns and provide them an authentic voice would inform the profession. Research on the hierarchical structures of the nurse-physician relationship within the hospital environment and its effect on patient care outcomes would enrich the literature.

Review and Synthesize Completed Research Through Systematic Review

The evidence-based health care movement has generated new opportunity for scholars to generate synthesized sources of evidence. Systematic reviews are rigorous forms of synthesized evidence that scholars can conduct if they have requisite skills, time, and access to excellent library resources. Systematic reviews play an important role in synthesizing what is known and unknown about a particular health issue. Thus, they have a synergistic relationship with primary research. They can both inform clinical decisions when the evidence is adequate and identify gaps in knowledge to inform research priorities. Systematic reviews can be conducted of quantitative and qualitative evidence to answer many types of questions. They all share characteristics of rigor that arise from a priori protocol development, transparency, exhaustive searching, dual independent reviewers who critically appraise studies using standardized tools, rigor in synthesis, and peer review at multiple stages in the conduct and reporting of the systematic review.

A comprehensive systematic review on lateral/horizontal violence in the profession of nursing

Review Questions/Objective The overall aim of this comprehensive systematic review is to synthesise the best available evidence on the experience of lateral/horizontal violence in the profession of nursing and the effectiveness of programs/strategies meant to decrease its prevalence or mitigate its negative effects. Specifically, this review will seek to answer the following questions: •What is the experience of being a licensed nurse who is a victim of lateral/horizontal violence? •What is the experience of being a student nurse who is a victim of lateral/horizontal violence? •What is the impact of experiencing lateral/horizontal violence on job retention and job satisfaction? •What are the most effective interventions/strategies for decreasing the prevalence or mitigating the negative effects of lateral/horizontal violence on licensed nurses? Inclusion Criteria Types of Participants This review will consider studies with a focus on licensed nurses and student nurses. For purposes of this review ‘licensed nurse’ refers to a nurse who holds a license to practice nursing at any level. Due to the ambiguity of nomenclature, different titles for licensed nurse will be considered, including but not limited to registered nurse, practical nurse, vocational nurse.) Types of Interventions/Phenomena of Interest The qualitative component of this review will consider as phenomena of interest the actual experience of horizontal/lateral violence by licensed nurses and student nurses. The quantitative component of this review will examine interventions/strategies meant to decrease the prevalence or mitigate the effects of lateral/horizontal violence on licensed or student nurses. Some examples of programs or strategies reported in the literature are intense education programs, cognitive rehearsal strategies, zero tolerance policies and workshops. Context This review will consider research on the experience of lateral/horizontal violence in the profession of nursing and the efficacy/effectiveness of programs/strategies that are designed to decrease its prevalence or mitigate its negative effects in any setting where licensed or student nurses practise. Types of Outcomes The qualitative component of this review will include experiential accounts of being a nurse or student nurse who has experienced lateral/horizontal violence. The quantitative component of this review will consider studies that report outcomes such as but not limited to: •types and intensity/severity of effects of lateral/horizontal violence on licensed or student nurses •number of lateral/horizontal violence episodes/ prevalence of lateral/horizontal violence. •job satisfaction •job retention.

Assessment of Risk for In-Hospital Suicide and Aggression in High-Dependency Care Environments

High-dependency environments are complex both from the standpoint of diversity of patient types and the nature of their functioning. Nurses manage this complexity at many different levels. Being attuned not only to the physical status of the patient but also the emotional/psychological status is paramount in maintaining a safe environment. Staff training and education is paramount in reducing risk. Institutions have a responsibility to provide resources to develop violence prevention programs.

The Meaning of Being in Protective / Source Isolation for Hospitalized Patients: A Systematic Review

Review Question/Objective: The overall objective of this systematic review is to synthesize the best available evidence on the meaning of being in isolation from the hospitalized patient’s perspective for both protection and as a barrier for hospitalized patients. Criteria for considering studies for this review: Types of Participants: This review will consider hospitalized adult patients in isolation for protection from others or as a barrier to prevent the transmission of infection. Phenomena of Interest: The phenomenon of interest consists of patients’ experience, perceptions and meanings from being in isolation. The setting will be limited to hospital environments. The context will be patients in isolation as both a protective measure and as a barrier for crossinfection.