In the context of new reimbursement systems like diagnosis-related groups, moral distress is becoming a growing problem for healthcare providers. Moral distress can trigger emotional and physical reactions in nurses and can cause them to withdraw emotionally from patients or can cause them to change their work place.
Objective:
The aim of this pilot study was to develop an instrument to measure moral distress among acute care nurses in the German-speaking context, to test its applicability, and to obtain initial indications of the instrument’s validity.
Method:
The study was designed in 2011 as a cross-sectional pilot survey. Conducted on eight units of one university hospital in German-speaking Switzerland, 294 registered nurses were asked to fill out a web-based questionnaire on moral distress.
Ethical considerations:
The study proposal was approved by the cantonal ethics committee. All participating nurses provided informed consent and were assured of data confidentiality.
Results:
The survey had a response rate of 55%. The results show the prevalence of statements on the questionnaire indicating situations with the potential to trigger moral distress. The entire range of answers was used in the responses. Most participants found the questionnaire comprehensible, while some criticized the phraseology of certain statements. Many more found the registration process prior to online access to be too time consuming. Nurses confirmed that the results reflect their subjective assessment of their situation and their experience of moral distress.
Conclusion:
The newly developed moral distress questionnaire appears to produce face validity and is sufficiently applicable for use in our study. The results indicate that moral distress appears to be a relevant phenomenon also in Swiss hospitals and that nurses were experiencing it prior to the introduction of Swiss diagnosis-related groups.
ZuzeloPR. Exploring the moral distress of registered nurses. Nurs Ethics2007; 14(3): 344–359(PMID: 17459818).
2.
ElpernEHCovertBKleinpellR. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care2005; 14(6): 523–530.
3.
RiceEMRadyMYHamricAB. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. J Nurs Manag2008; 16(3): 360–373(PMID: 18324996).
4.
CorleyMCElswickRKGormanM. Development and evaluation of a moral distress scale. J Adv Nurs2001; 33(2): 250–256(PMID: 11168709).
5.
HamricABDavisWSChildressMD. Moral distress in health care professionals. Pharos Alpha Omega Alpha Honor Med Soc2006; 69(1): 16–23.
6.
WilkinsonJM. Moral distress in nursing practice: experience and effect. Nurs Forum1987–1988; 23(1): 16–29.
7.
GutierrezKM. Critical care nurses’ perceptions of and responses to moral distress. Dimens Crit Care Nurs2005; 24(5): 229–241.
8.
HamricABBorchersCTEpsteinEG. Development and testing of an instrument to measure moral distress in health care professionals. AJOB Prim Res2012; 3(2): 1–9.
9.
HamricABBlackhallLJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med2007; 35(2): 422–429.
LützénKKvistBE. Moral distress: a comparative analysis of theoretical understandings and inter-related concepts. HEC Forum2012; 24(1): 13–25.
12.
HamricAB. Empirical research on moral distress: issues, challenges, and opportunities. HEC Forum2012; 24(1): 39–49.
13.
KälvemarkSHoglundATHanssonMG. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med2004; 58(6): 1075–1084(PMID: 14723903).
14.
SilénMSvantessonMKjellströmS. Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability. J Clin Nurs2011; 20: 3483–3493.
15.
CorleyMC. Moral distress of critical care nurses. Am J Crit Care1995; 4(4): 280–285.
16.
PapathanassoglouEDEKaranikolaMNKKalafatiM. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care2012; 21(2): e41–e52.
17.
LauxenO. Moralische Probleme in der ambulanten Pflege—eine deskriptive pflegeethische Untersuchung. [Moral problems in home health care–a descriptive ethical study]. Pflege2009; 22(6): 421–430.
18.
TewesR. Moralische Intelligenz: wertorientierte Führung zahlt sich aus [Moral Intelligence: value-based management pays for itself]. In: TewesR (ed.) Führungskompetenz ist lernbar[Leadership can be learned]. 2. Auflage ed. Berlin, Heidelberg: Springer, 2011, pp. 47–60.
19.
ZimmermannPJacobsHKowalskiJT. ISAF und die Seele—zwischen Schädigung und Wachstum [ISAF and the soul - between damage and growth]. In: SeiffertALangerPCPietschC (eds) Der Einsatz der Bundeswehr in Afghanistan[Deployment of the German military in Afghanistan]. Berlin, Heidelberg: Springer, 2012, pp. 143–152.
20.
Albisser SchlegerHParggerHReiter-TheilS. “Futility”—Übertherapie am Lebensende? Gründe für ausbleibende Therapiebegrenzung in Geriatrie und Intensivmedizin [“Futility” - Overtreatment at the End of Life? Reasons for Missed Cessations of Therapy in Geriatric and Critical Care Medicine]. Zeitschrift für Palliativmedizin2008; 9: 67–75.
21.
NienhausAWestermannCKuhnertS. Burn-out bei Beschäftigten in der stationären Altenpflege und in der Geriatrie [Burnout among elderly care staff. A review of its prevalence]. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz2012; 55(2): 211–222.
22.
LützénKCronqvistAMagnussonA. Moral stress: synthesis of a concept. Nurs Ethics2003; 10(3): 312–322.
23.
Mashiach EizenbergMDesivilyaHSHirschfeldMJ. Moral distress questionnaire for clinical nurses: instrument development. J Adv Nurs2009; 65(4): 885–892.
24.
LazzarinMBiondiADi MauroS. Moral distress in nurses in oncology and haematology units. Nurs Ethics2012; 19(2): 183–195.
25.
OhnishiKOhgushiYNakanoM. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics2010; 17(6): 726–740.
26.
HarrowingJNMillJ. Moral distress among Ugandan nurses providing HIV care: a critical ethnography. Int J Nurs Stud2010; 47: 723–731.
27.
PiersRDVan den EyndeMSteemanE. End-of-life care of the geriatric patient and nurses’ moral distress. J Am Med Dir Assoc2012; 13: 80.e7–80.e13.
28.
SpirigRSpichigerEMartinJS. Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals. Ger Med Sci2014; 12: Doc07.
29.
SwissDRG AG. Fallpauschalen in Schweizer Spitälern, Basisinformationen für Gesundheitsfachleute[Case-based prospective payment systems in Swiss hospitals, basic information for health care professionals]. Bern: SwissDRG AG, 2010.
30.
Biller-AndornoNWildV. Impact of Diagnosis Related Groups (DRGs) on patient care and professional practice (IDoC): Universität Zürich—Ethik-Zentrum—Institut für Biomedizinische Ethik, http://www.ethik.uzh.ch/ibme/forschung/drg.html(2010, accessed 5 February 2013).
31.
LawrenceLA. Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nurs Forum2011; 46(4): 256–268.
32.
MartinJSVincenziCSpirigR. Prinzipien und Methoden einer wissenschaftlich akkuraten Übersetzungspraxis von Instrumenten für Forschung und direkte Pflege [Principles and methods of good practice for the translation process for instruments of nursing research and nursing practice]. Pflege2007; 20(3): 157–163.
33.
JonesPSLeeJWPhillipsLR. An adaptation of Brislin’s translation model for cross-cultural research. Nurs Res2001; 50(5): 300–304(PMID: 11570715).
34.
CorleyMC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics2002; 9(6): 636–650(PMID: 12450000).
35.
Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner SBK. Ethik in der Pflegepraxis[Ethics in nursing practice].Bern: Zentralsekretariat SBK, 2003.
36.
Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner SBK. Ethische Standpunkte 2, Verantwortung und Pflegequalität[Ethical viewpoints 2, accountability and quality of care]. Bern: Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner, 2007.
KongsvedSMBasnovMHolm-ChristensenK. Response rate and completeness of questionnaires: a randomized study of internet versus paper-and-pencil versions. J Med Internet Res2007; 9(3): e25.
39.
BrockRLBarryRALawrenceE. Internet administration of paper-and-pencil questionnaires used in couple research: assessing Psychometric Equivalence. Assessment2012; 19(2): 226–242.
40.
WhiteheadL. Methodological issues in internet-mediated research: a randomized comparison of internet versus mailed questionnaires. J Med Internet Res2011; 13(4): e109.
41.
DillmanDAChristianLM. Survey mode as a source of instability in responses across surveys. Field Method2005; 17(1): 30–52.
42.
Van SchaikPLingJ. Design parameters of rating scales for web sites. ACM Trans Comput Hum Interact2007; 14(1): 1–35.
43.
CribbA. Integrity at work: managing routine moral stress in professional roles. Nurs Philos2011; 12: 119–127.
44.
CronqvistATheorellTBurnsT. Caring about—caring for: moral obligations and work responsibilities in intensive care nursing. Nurs Ethics2004; 11(1): 63–76.
45.
MeltzerLSHuckabayLM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care2004; 13(3): 202–208.
46.
WiggletonCPetrusaELoomisK. Medical students’ experiences of moral distress: development of a web-based survey. Acad Med2010; 85(1): 111–117.
47.
PaulyBVarcoeCStorchJ. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics2009; 16(5): 561–573(PMID: 19671643).
48.
SchluterJWinchSHolzhauserK. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics2008; 15(3): 304–321(PMID: 18388166).
