Developing an evidence-and ethics-informed intervention for moral distress.

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic's trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach to develop a moral distress intervention-proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness.

Moral Distress and Nursing Education: Curricular and Pedagogical Strategies for a Complex Phenomenon.

Moral distress is a common phenomenon among nurses and is related to the complicated work environments and complex nature of ethical situations in day-to-day nursing practice. Moral distress impacts nurses as well as patient care and the health care system. Few strategies have been identified for instructors to effectively engage with learners when communicating about moral distress. We discuss two key curricular and pedagogical strategies that should be utilized when learning about moral distress: difficult knowledge' and 'terror management theory'. Whether it is with new nursing students or experienced nurses, there is necessary learning that needs to occur on moral distress. Difficult knowledge' and 'terror management theory', when implemented, can provide a starting point for both the learner and the instructor to discuss the emotionally difficult and complex topic of moral distress. Knowledge about moral distress has the potential to mitigate its negative effects, therefore it is vital to consider educational strategies to teach nurses about this complex phenomenon.

Family perspectives of ex situ heart perfusion.

BACKGROUND: Pediatric patients awaiting a heart transplant have high waitlist mortality. Several strategies have been utilized to decrease waiting times, but a mortality risk still exists. New medical technologies may improve waiting times and associated mortality. Ex situ heart perfusion (ESHP) is one such technology, which can decrease the impact of cold ischemia on the donor heart and allow for a longer out-of-body time. Adoption of such technology in pediatric heart transplantation will require support from end users, including patient and families. The aim of this qualitative study was to report the perspectives of families with experience related to pediatric HTx toward ESHP. METHODS: Semistructured interviews were conducted with 12 parents or guardians of children who were awaiting or received heart transplantation. Interviews were transcribed, and data were analyzed using qualitative content analysis. RESULTS: Participants expressed varied awareness and knowledge of ESHP. Independent of their understanding of ESHP, all purported that ESHP was an excellent idea and that this technology should be implemented in the pediatric population. They did not identify fundamentally different ethical issues or concerns for ESHP being used relative to other medical technologies. Overall, most participants described consent processes for ESHP should be like any other procedure. All agreed that the surgeon should continue to describe the overall health of the donor heart, provide their medical recommendations, and allow families to have the final say. CONCLUSIONS: The concepts described by the parents and guardians are important in moving this novel technology forward. This information will serve the basis for knowledge translation that will provide educational resources to broaden the understanding and reach of ESHP.

Mitigating Moral Distress: Pediatric Critical Care Nurses' Recommendations.

In pediatric critical care, nurses are the primary caregivers for critically ill children and are particularly vulnerable to moral distress. There is limited evidence on what approaches are effective to minimize moral distress among these nurses. To identify intervention attributes that critical care nurses with moral distress histories deem important to develop a moral distress intervention. We used a qualitative description approach. Participants were recruited using purposive sampling between October 2020 to May 2021 from pediatric critical care units in a western Canadian province. We conducted individual semi-structured interviews via Zoom. A total of 10 registered nurses participated in the study. Four main themes were identified: (1) "I'm sorry, there's nothing else": increasing supports for patients and families; (2) "someone will commit suicide": improving supports for nurses: (3) "Everyone needs to be heard": improving patient care communication; and (4) "I didn't see it coming": providing education to mitigate moral distress. Most participants stated they wanted an intervention to improve communication among the healthcare team and noted changes to unit practices that could decrease moral distress. This is the first study that asks nurses what is needed to minimize their moral distress. Although there are multiple strategies in place to help nurses with difficult aspects of their work, additional strategies are needed to help nurses experiencing moral distress. Moving the research focus from identifying moral distress towards developing effective interventions is needed. Identifying what nurses need is critical to develop effective moral distress interventions.

Factors Influencing Older Persons' Transitions to Facility-Based Care Settings: A Scoping Review.

BACKGROUND AND OBJECTIVES: Older adults (≥65 years) are living longer with complex health needs and wish to remain at home as their care needs change. We aimed to determine which factors influence older persons' transitions from home living to facility-based care (FBC) settings such as long-term care facilities or assisted living. RESEARCH DESIGN AND METHODS: Through a scoping review of 7 databases, we considered all academic literature examining factors influencing transitions from home living to FBC. Only English articles were reviewed. Based on the Meleis' Health Transition (MHT) model, we categorized findings into: (a) transition conditions; (b) patterns of response; and (c) health services and interventions. RESULTS: We included 204 unique studies. Age, cognitive/functional impairments, and caregiver burden were the most consistent risk factors for older persons' transitions to FBC. Caregiver burden was the only consistent risk factor in both quantitative and qualitative literature. Other factors around health service use or nonmedical factors were examined in a small number of studies, or demonstrated mixed or nonsignificant results. Key research gaps relate to transitions to intermediate levels of FBC, research in public health systems, and research employing qualitative and interventional methods. DISCUSSION AND IMPLICATIONS: We expanded the MHT model to capture informal caregivers and their critical role in transitions from home to FBC settings. More research is needed to address practical needs of clients and caregivers while at home, and self-directed care funding models could be expanded. Theory-driven interventional research focusing on caregivers and successful hospital discharge is critically needed.

Barriers and misconceptions of ex situ heart perfusion in pediatric donation.

BACKGROUND: Despite efforts, pediatric HTx candidates continue to have high waitlist mortality due to limited donor availability. However, there is a significant number of offered hearts not used due to concerns of viability. ESHP is a method for continuous perfusion of the donor heart that allows assessment and extended out-of-body time. It is imperative to understand healthcare stakeholders' perspectives on ESHP for implementation. Therefore, the aims of this qualitative study were to: (1) Explore pediatric stakeholders' perspectives toward ESHP; and (2) Identify barriers to widespread adoption of this technology. METHODS: Virtual focus groups were completed with pediatric HTx healthcare professional stakeholders. Following transcription of audio-recordings, the material was analyzed using content analysis. RESULTS: Four focus groups were completed with 17 participants, representing 12 institutions and three countries. Focus groups revealed varied understanding of both current and potential uses of ESHP. Participants did see the potential benefits of extending out-of-body time for and the ability to evaluate donor heart quality. However, concerns were expressed relating to patient selection, wait-list times, post-HTx outcomes, adverse events, and technical issues. These were felt to be important to understand in order to justify the costs of ESHP and impact on the healthcare system. CONCLUSIONS: This project represents the first qualitative formative evaluation of ESHP in pediatrics. The knowledge gained from stakeholders will form the basis for education initiatives, clinical trial design, and roll-out of new ESHP technologies designed for pediatrics.

Recommendations for navigating the experiences of moral distress: A scoping review.

BACKGROUND: Moral distress is a complex ethical phenomenon that occurs when one is not able to act according to their moral judgement. Consequences of moral distress negatively impact nurses, patient care, and the healthcare system. There is limited evidence on specific approaches to prepare nurses to manage these ethical situations. AIM: The aim of this scoping review is to identify moral distress interventions for nurses who provide direct patient care, identify gaps in the current moral distress research, and determine areas of focus for future research on this topic. METHODS: We employed the framework outlined by Levac, Colquhoun, and O'Brien and Arksey and O'Malley to conduct a scoping review. These steps included the: identification of the research question, identification of relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. We appraised the quality of included studies using the Mixed Methods Appraisal Tool. RESULTS: We identified 5206 articles from the selected databases. Once duplicates were removed, two independent reviewers each screened 4043 title and abstracts. We included 554 articles for full-text screening, with 10 studies included based on inclusion and exclusion criteria. Study designs included before-after studies (n = 4), randomized control trials (n = 3), concurrent mixed-methods studies (n = 2), and one controlled before-after study. All studies were conducted in acute care settings. In four studies, interventions focused on informing nurses on moral distress. Two interventions focused on increasing the nurses' reflexivity on their workplace experiences. One intervention included formal clinical mentoring and clinical ethics support through interprofessional rounds. Two studies utilized a multicomponent intervention. The overall moral distress scores significantly decreased after intervention implementation in three included studies. Three additional studies showed significant differences in specific survey item scores (e.g., "provision of less-than-optimal care" and "caring for patients they did not feel qualified to care for"), as compared to overall scores, after intervention implementation. In 70% of studies the amount of quality criteria met were 60% or higher according to the Mixed Methods Appraisal Tool. CONCLUSION: Our review is the first to synthesize intervention studies pertaining to moral distress among nurses. The findings of this review demonstrate that there is no clear pattern regarding which strategies consistently minimize the effects of moral distress among nurses. Future interventions should be tested more broadly by increasing the sample size, assessing length of intervention in relation to moral distress scores, expanding the interventions to other units and institutions, and including other healthcare professionals. Tweetable abstract: We reviewed interventions to help nurses with moral distress. Findings show no clear pattern of strategies to minimize their moral distress.

Moral distress: A concept clarification.

BACKGROUND: Over the past few decades, moral distress has been examined in the nursing literature. It is thought to occur when an individual has made a moral decision but is unable to act on it, often attributable to constraints, internal or external. Varying definitions can be found throughout the healthcare literature. This lack of cohesion has led to complications for study of the phenomenon, along with its effects to nursing practice, education and targeted policy development. OBJECTIVES: The aim of this analysis was to uncover unique definitions of moral distress as found in the nursing literature and to examine the relationship between these definitions. RESEARCH DESIGN AND CONTEXT: Morse's method of concept clarification was applied given the large body of literature which includes definitions, descriptions and measurements of the concept in research. The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing, and contrasting attributes, antecedents and consequences of each category. FINDINGS: Each of the 18 included studies described constraints in their definition of moral distress, whether implied or explicitly stated. External constraints are widely described as obstacles outside of the individual, whether institutional, systemic or situational, while internal constraints are located within the individuals themselves and are described as personal limitations, failings or weakness of will. CONCLUSION: Upon reviewing these definitions, we determined that the term 'internal constraints' is problematic due to the emphasis of responsibility on the individual experiencing moral distress. We propose an alteration to 'internal characteristics' that will assume less responsibility of change from the individual to place a heavier onus on systemic and institutional constraints.

Situating moral distress within relational ethics.

Nurses may, and often do, experience moral distress in their careers. This is related to the complicated work environment and the complex nature of ethical situations in everyday nursing practice. The outcomes of moral distress may include psychological and physical symptoms, reduced job satisfaction and even inadequate or inappropriate nursing care. Moral distress can also impact retention of nurses. Although research has grown considerably over the past few decades, there is still a great deal about this topic that we do not know including how to deal well with moral distress. A critical key step is to develop a deeper understanding of relational practice as it pertains to moral distress. In this article, exploration of the experience of moral distress among nurses is guided by the key elements of relational ethics. This ethical approach was chosen because it recognizes that ethical practice is situated in relationships and it acknowledges the importance of the broader environment on influencing ethical action. The findings from this theoretical exploration will provide a theoretical foundation upon which to advance our knowledge about moral distress.