Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned.

BACKGROUND: The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. METHODS: A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. RESULTS: All 178 respondents (response rate: 25-32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to 'team cooperation', 'team solidarity' and 'work ethic'. Lessons learned were mostly related to 'quality of care' and 'professional qualities'. CONCLUSIONS: Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals' dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. TRIAL REGISTRATION: The trial was registered on The Netherlands Trial Register, number NL9177.

How does ethical climate enhance work–family enrichment? Insights from psychological attachment, psychological capital and job autonomy in the restaurant industry

PurposeThis study aims to propose a conceptual model that examines the role of ethical climate on work–family enrichment in the restaurant industry, which is one of the most vulnerable sectors affected by global crises such as the COVID-19 pandemic. The mediating effects of psychological attachment and psychological capital and the moderating effects of job autonomy were also investigated to enrich understanding of ethical climate and work–family enrichment.Design/methodology/approachThe conceptual model was evaluated by using a quantitative–qualitative mixed-methods approach. In Study 1, survey data was collected from a sample of 405 restaurant frontline employees and analyzed using partial least squares structural equation modeling. In Study 2, interviews were conducted with eight restaurant frontline employees and analyzed thematically. The data for Study 1 and Study 2 was collected from Jharkhand, a state in eastern India.FindingsThe results of Study 1 show a direct relationship between ethical climate and work–family enrichment. The mediating effect of psychological attachment and psychological capital on that direct relationship was also established, whereas job autonomy was found to be a significant moderator that negatively affects psychological attachment and work–family enrichment. The qualitative insights in Study 2 shed additional light on the rationales of the effects observed in Study 1 through the voices of restaurant frontline employees whilst triangulating the quantitative findings in Study 1.Research limitations/implicationsThis research contributes novel insights that explain how ethical climate positively shapes work–family enrichment through the lens of psychological attachment and psychological capital, albeit cautiously, given the negative effect of job autonomy. Nevertheless, this research remains limited to restaurant frontline employees, thereby necessitating future research in other service industries to improve the generalizability of its findings.Originality/valueThis research offers a seminal extension of the direct effect of ethical climate on work–family enrichment (i.e. the "what”) by theorizing and validating the mediating (i.e. the "why”) and moderating (i.e. the "how”) effects of psychological attachment, psychological capital and job autonomy.

Moral distress and ethical climate in pediatric nurses in the time of COVID

Moral Distress in an increasing problem in nurses and other healthcare professionals due to the many challenges nurses face in proving care to their patients and families. These challenges can be magnified when the nurse is conflicted and unable to successfully navigate the moral and ethical responsibilities of the profession leading to moral distress. The COVID-19 pandemic has had profound and global widespread consequences including the impact on pediatric nurses. This descriptive correlational study examined the relationship between moral distress and ethical climate among pediatric nurses who cared for patients during the COVID-19 pandemic. This study used Corely's Theory of Moral Distress as the theoretical background to examine this relationship. The sample consisted of 81 pediatric inpatient nurses from across the US that were recruited by two professional organizations. All participants completed the Measure of Moral Distress - Healthcare Professionals (MMD-HP) the Hospital Ethical Climate Survey (HECS) and a demographic data collection tool developed by this researcher. The results of this study found a statistically significant inverse relationship between moral distress and perceived ethical climate among the study participants. Other demographic data information was analyzed and there were no significant findings for years of experience, type of education, and type of unit setting. However, there were statistically significant findings for those participants who stated they were considering leaving their position due to moral distress and those that were not, as well as those who stated they received adequate training to COVID-19 patients and those who stated they did not.This is the first known study to investigate the relationship between moral distress and perceived ethical climate in pediatric nurses who cared for patients during the COVID-19 pandemic. Since the end of the COVID-19 pandemic is not fully in sight, findings of this study will help bring awareness to this issue and promote improving an ethical climate in order to mitigate the feelings of moral distress. This is of paramount importance to mitigate the negative consequence of moral distress among pediatric nurses. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

How does ethical climate enhance work–family enrichment? Insights from psychological attachment, psychological capital and job autonomy in the restaurant industry

Purpose This study aims to propose a conceptual model that examines the role of ethical climate on work-family enrichment in the restaurant industry, which is one of the most vulnerable sectors affected by global crises such as the COVID-19 pandemic. The mediating effects of psychological attachment and psychological capital and the moderating effects of job autonomy were also investigated to enrich understanding of ethical climate and work-family enrichment. Design/methodology/approach The conceptual model was evaluated by using a quantitative-qualitative mixed-methods approach. In Study 1, survey data was collected from a sample of 405 restaurant frontline employees and analyzed using partial least squares structural equation modeling. In Study 2, interviews were conducted with eight restaurant frontline employees and analyzed thematically. The data for Study 1 and Study 2 was collected from Jharkhand, a state in eastern India. Findings The results of Study 1 show a direct relationship between ethical climate and work-family enrichment. The mediating effect of psychological attachment and psychological capital on that direct relationship was also established, whereas job autonomy was found to be a significant moderator that negatively affects psychological attachment and work-family enrichment. The qualitative insights in Study 2 shed additional light on the rationales of the effects observed in Study 1 through the voices of restaurant frontline employees whilst triangulating the quantitative findings in Study 1. Research limitations/implications This research contributes novel insights that explain how ethical climate positively shapes work-family enrichment through the lens of psychological attachment and psychological capital, albeit cautiously, given the negative effect of job autonomy. Nevertheless, this research remains limited to restaurant frontline employees, thereby necessitating future research in other service industries to improve the generalizability of its findings. Originality/value This research offers a seminal extension of the direct effect of ethical climate on work-family enrichment (i.e. the "what") by theorizing and validating the mediating (i.e. the "why") and moderating (i.e. the "how") effects of psychological attachment, psychological capital and job autonomy.

Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center.

BACKGROUND: Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave. METHODS: We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave. RESULTS: Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001). CONCLUSIONS: Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Moral distress in physicians

Moral distress, initially described as the form of distress that occurs "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action," is highly prevalent among physicians. Contemporary descriptions of moral distress involve three domains including negative attitudes one experiences, one's perceived involvement in a situation, and perceived moral undesirability of the situation. Common sources of moral distress stem from clinical situations and internal and external constraints. Interventions can be targeted at the root causes and components of moral injury and distress, on both individual and organizational levels. These include fostering resiliency in individual clinicians, providing support and moral leadership and ethical culture. This chapter will provide an overview of moral distress in physicians including definitions, common sources and constraints, as well as interventions with specific examples from oncology and the COVID-19 pandemic. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Palliative care practice and moral distress during COVID-19 pandemic (PEOpLE-C19 study): a national, cross-sectional study in intensive care units in the Czech Republic.

BACKGROUND: Providing palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors. METHODS: Between 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress. RESULTS: In total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% (n = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% (n = 113) of nurses and 71.6% of (n = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057-3.252; p = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128-0.430; p < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection. CONCLUSIONS: HCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate. TRIAL REGISTRATION: NCT04910243 .

Crisis, ethical leadership and moral courage: Ethical climate during COVID-19.

BACKGROUND: The global COVID-19 pandemic has challenged nurse leaders in ways that one could not imagine. Along with ongoing priorities of providing high quality, cost-effective and safe care, nurse leaders are also committed to promote an ethical climate that support nurses' moral courage for sustaining excellence in patient and family care. AIM: This study is directed to develop a structure equation model of crisis, ethical leadership and nurses' moral courage: mediating effect of ethical climate during COVID-19. ETHICAL CONSIDERATION: Approval was obtained from Ethics Committee at Faculty of Nursing, Alexandria University, Egypt. METHODS: A cross-sectional design was used to conduct this study using validated scales to measure the study variables. It was conducted in all units of two isolated hospitals in Damanhur, Egypt. A convenient sample of 235 nurses was recruited to be involved in this study. RESULTS: This study revealed that nurses perceived a moderate mean percent (55.49 ± 3.46) of overall crisis leadership, high mean percent (74.69 ± 6.15) of overall ethical leadership, high mean percent (72.09 ± 7.73) of their moral courage, and moderate mean percent of overall ethical climate (65.67 ± 12.04). Additionally, this study declared a strong positive statistical significant correlation between all study variables and indicated that the independent variable (crisis and ethical leadership) can predict a 0.96, 0.6, respectively, increasing in the dependent variable (nurses' moral courage) through the mediating impact of ethical climate. CONCLUSION: Nursing administrators should be conscious of the importance of crisis, ethical leadership competencies and the role of ethical climate to enhance nurses' moral courage especially during pandemic. Therefore, these findings have significant contributions that support healthcare organizations to develop strategies that provide a supportive ethical climate. Develop ethical and crisis leadership competencies in order to improve nurses' moral courage by holding meetings, workshops, and allowing open dialogue with nurses to assess their moral courage.

Factors influencing public health nurses' ethical sensitivity during the pandemic.

BACKGROUND: Ethical sensitivity is a prerequisite for ethical nursing practices. Efforts to improve nurses' ethical sensitivity are required to correctly recognise ethical conflicts and for sound decision-making. Because an emerging infectious disease response involves complex ethical issues, it is important to understand the factors that influence public health nurses' ethical sensitivity while caring for patients with COVID-19, an emerging infectious disease. OBJECTIVES: This study aims to identify the relationship between nursing professionalism, the organisation's ethical climate, and the ethical sensitivity of nurses who care for emerging infectious disease patients in Korean public health centres. Further, it sought to identify factors influencing ethical sensitivity and the mediating effect of the organisational ethical climate to inform guidelines and improve ethical sensitivity. RESEARCH DESIGN: This was a cross-sectional descriptive study. PARTICIPANTS AND RESEARCH CONTEXT: Data were collected from February 3 to 8 March 2021. Participants included 167 nurses caring for patients with COVID-19 in public health centres in South Korea. ETHICAL CONSIDERATION: This study was approved by the Institutional Review Board of the Chung-Ang University and followed the principles of research ethics. RESULTS: The factors influencing ethical sensitivity were working at a COVID-19 disease direct response department, nursing professionalism, and organisation's ethical climate. The organisation's ethical climate showed a partial mediating effect on the influence of nursing professionalism on ethical sensitivity. CONCLUSION: Our findings show that nurses' ethical sensitivity can be improved by refining the organisation's ethical climate and nursing professionalism.

Experiences of critical care nurses during the early months of the COVID-19 pandemic.

BACKGROUND: Critical care nurses have risked their lives and in some cases their families through hazardous duty during the COVID-19 pandemic and have faced multiple ethical challenges. RESEARCH/AIM: The purpose of our study was to examine how critical care nurses coped with the sustained multi-faceted pressures of the critical care environment during the unchartered waters of the COVID-19 pandemic. It was anticipated that our study might reveal numerous ethical challenges and decision points. RESEARCH DESIGN: A qualitative descriptive study, utilizing an interpretivist paradigm. PARTICIPANTS AND RESEARCH SETTING: Critical care nurses, working in either intensive care units or emergency departments (N = 11) who were primarily from Northern California hospitals. Individual in-depth ZOOM® session interviews, guided by semi-structured questions, were used to collect data. Interviews lasted between 18 and 59 min, with an average length of 33 min. Session interviews were transcribed and analyzed. ETHICAL CONSIDERATIONS: This study was approved by the researchers' university Institutional Review Board. FINDINGS: Five main themes emerged: Fear of the Unknown, Adapting to Practice Changes and Challenges, Patient Advocacy and Moral Distress, Isolation and the Depersonalization of Care, and Professionalism and a Call to Duty. DISCUSSION AND CONCLUSION: Fear of becoming ill or bringing COVID-19 home to their families was a constant source of anxiety for nurses. There were numerous changes in policy and challenges to standard practice protocols, including most notably shortages in personal protective equipment, which nurses navigated resourcefully. Most nurses interviewed were motivated by a sense of professional duty. The nurses experienced some moral distress in their inability to advocate as they might like for their patients, especially at end of life. Infection control requirements for isolation.

The association between perceived hospital ethical climate and self-evaluated care quality for COVID-19 patients: the mediating role of ethical sensitivity among Chinese anti-pandemic nurses.

BACKGROUND: The COVID-19 pandemic called for a new ethical climate in the designated hospitals and imposed challenges on care quality for anti-pandemic nurses. Less was known about whether hospital ethical climate and nurses' ethical sensitivity were associated with care quality. This study examined the association between the perceived hospital ethical climate and self-evaluated quality of care for COVID-19 patients among anti-pandemic nurses, and explored the mediating role of ethical sensitivity in this relationship. METHODS: A cross-sectional study was conducted through an online survey. A total of 399 anti-pandemic nurses from ten designated hospitals in three provinces of China were recruited to fill out an online survey. Multiple linear regression analysis and a bootstrap test were used to examine the relationships between ethical climate, ethical sensitivity and care quality. RESULTS: Nurses reported mean scores of 4.43 ± 0.577 (out of 5) for hospital ethical climate, 45.00 ± 7.085 (out of 54) for ethical sensitivity, and 5.35 ± 0.661 (out of 6) for self-evaluated care quality. After controlling for covariates, perceived hospital ethical climate was positively associated with self-evaluated care quality (direct effect = 0.710, 95% confidence interval [CI] 0.628, 0.792), and was partly mediated by ethical sensitivity (indirect effect = 0.078, 95% confidence interval [CI] 0.002, 0.145). CONCLUSIONS: Chinese nurses who cared for COVID-19 patients perceived high levels of hospital ethical climate, ethical sensitivity, and self-evaluated care quality. Positive perceptions of hospital ethical climate were both directly associated with a higher level of self-evaluated care quality and indirectly associated, through the mediation effect of ethical sensitivity among anti-pandemic nurses.

Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study.

BACKGROUND: The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. METHODS: An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. RESULTS: Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. "Inadequate emotional support for patients and their families" was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. "Culture of not avoiding end-of-life-decisions" and "Self-reflective and empowering leadership" received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior. CONCLUSION: Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.

Priority-setting dilemmas, moral distress and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway.

BACKGROUND: The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees' moral stress and job satisfaction. AIM: Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. RESEARCH DESIGN: A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. ETHICAL CONSIDERATIONS: Ethical approval granted by the Regional Research Ethics Committee in Western Norway (131421). FINDINGS: Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0-10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. DISCUSSION: By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority. CONCLUSION: Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms.