Practical ethical challenges and moral distress among staff in a hospital
            COVID
            ‐19 screening service

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver Protocol. Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress.

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Enabling first and second year doctors to negotiate ethical challenges in end-of-life care: a qualitative study

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2020-002672 ◽

2021 ◽

pp. bmjspcare-2020-002672

Author(s):

Sinead Donnelly ◽

Simon Walker

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Moral Distress ◽

Well Being ◽

First Year ◽

Life Care ◽

Ethical Challenges ◽

Life And Death ◽

Medicine Physician ◽

Second Year

ObjectiveTo understand the unique ethical and professional challenges confronting first and second year doctors in caring for people who are dying, and to learn what factors help or hinder them in managing these.Method6 first year and 7 second year doctors were interviewed one-to-one by a senior palliative medicine physician (SD), quarterly over 12 months, using a semistructured approach. Thematic analysis was conducted with the findings, following the general inductive approach.Results21 hours of recorded interviews were analysed by SD, and ethical and professional issues were identified. These were discussed with SW, and sorted into seven broad categories. The participants’ accounts of the issues convey a strong ethical sensitivity, developed through their undergraduate training. A recurring challenge for them through their first 12–24 months of work as doctors is being responsible for the decisions, knowing that what they do can have life and death consequences. The participants frequently describe senior doctors as an important source of support, and the lack of such support as leading to moral distress and demoralisation. Another important factor is having opportunity to discuss and reflect on the decisions after they are made. Where such reflection had been facilitated properly, participants displayed considerable growth in their ability to manage ethical challenges.ConclusionSenior support and opportunities for reflection need to be recognised as key factors in enabling first and second year to respond appropriately to ethical challenges in end-of-life care, and in sustaining their well-being through this critical stage of their professional life.

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Evaluating underpinning, complexity and implications of ethical situations in humanitarian operations: qualitative study through the lens of career humanitarian workers

BMJ Open ◽

10.1136/bmjopen-2020-039463 ◽

2020 ◽

Vol 10 (9) ◽

pp. e039463

Author(s):

Ramin Asgary ◽

Katharine Lawrence

Keyword(s):

Decision Making ◽

Social Constructivism ◽

Moral Distress ◽

Unintended Consequences ◽

Aid Effectiveness ◽

International Agency ◽

Negative Consequences ◽

Ethical Challenges ◽

Ethical Frameworks ◽

Humanitarian Operations

IntroductionData regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited.MethodsWe conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations.Results61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks.ConclusionsEthical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.

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Organizational ethics: A literature review

Nursing Ethics ◽

10.1177/0969733011401123 ◽

2011 ◽

Vol 18 (3) ◽

pp. 285-303 ◽

Cited By ~ 38

Author(s):

Riitta Suhonen ◽

Minna Stolt ◽

Heli Virtanen ◽

Helena Leino-Kilpi

Keyword(s):

Literature Review ◽

Moral Distress ◽

Empirical Studies ◽

Organizational Ethics ◽

Ethical Challenges ◽

Healthcare Organizations ◽

Cross Sectional ◽

Ethical Climates ◽

Conceptual Clarity ◽

Large Research

The aim of the study was to report the results of a systematically conducted literature review of empirical studies about healthcare organizations’ ethics and management or leadership issues. Electronic databases MEDLINE and CINAHL yielded 909 citations. After a two stage application of the inclusion and exclusion criteria 56 full-text articles were included in the review. No large research programs were identified. Most of the studies were in acute hospital settings from the 1990s onwards. The studies focused on ethical challenges, dilemmas in practice, employee moral distress and ethical climates or environments. Study samples typically consisted of healthcare practitioners, operational, executive and strategic managers. Data collection was mainly by questionnaires or interviews and most of the studies were descriptive, correlational and cross-sectional. There is need to develop conceptual clarity and a theoretical framework around the subject of organizational ethics and the breadth of the contexts and scope of the research needs to be increased.

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Analytical study of care quality and moral distress in clinical situations and patient care

Frontiers of Nursing ◽

10.2478/fon-2019-0037 ◽

2019 ◽

Vol 6 (4) ◽

pp. 327-334

Author(s):

Masoumeh Hasanlo ◽

Arezo Azarm ◽

Parvaneh Asadi ◽

Kourosh Amini ◽

Hossein Ebrahimi ◽

...

Keyword(s):

Decision Making ◽

Patient Care ◽

Analytical Study ◽

Moral Distress ◽

Professional Competence ◽

Care Quality ◽

Nursing Profession ◽

Ethical Challenges ◽

Significant Difference ◽

Distress Scale

Abstract Objective Nursing profession conventionally meets a high standard of ethical behavior and action. One of the ethical challenges in nursing profession is moral distress. Nurses frequently expose to this phenomenon which leads to different consequences such as being bored by delivering patient care that decline care quality and make it challenging to achieve health purposes. This study was conducted to investigate the association between the aspects of moral distress and care quality. Methods In this descriptive–analytical study, 545 nurses of intensive and cardiac care units and dialysis and psychiatric wards were recruited by census sampling. Three questionnaires, Sociodemographics, Moral Distress Scale, and Quality Patient Care Scale, were distributed among the participants and collected within 9 months. Data analysis was conducted by descriptive statistics, analysis of variance, and the least significant difference in SPSS 13. Results Investigating moral distress domains (ignoring patient, decision-making power, and professional competence) and care quality domains (psychosocial, physical, and communicational) demonstrated that in being exposed to moral distress, ignoring patient had no effect on psychosocial domain (P=0.056), but decision-making and professional competence of moral distress had positive effect on psychosocial, physical (bodily), and communication domains of care quality. Conclusions Because moral distress domains are effective on patient care quality, it is recommended to enhance the knowledge of nurses, especially beginners, about moral distress, increase their strength alongside standardizing nursing services in decision-making domains, improve the professional competence, and pay attention to patients.

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Between the patient and the next of kin in end-of-life care: A critical study based on feminist theory

Nursing Ethics ◽

10.1177/0969733016688939 ◽

2017 ◽

Vol 26 (1) ◽

pp. 201-211 ◽

Cited By ~ 2

Author(s):

Ellen Ramvi ◽

Venke Irene Ueland

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Moral Distress ◽

Moral Identity ◽

Critical Study ◽

Life Care ◽

Ethical Challenges ◽

Next Of Kin ◽

Science Data ◽

Kin Relationship

Background: For the experience of end-of-life care to be ‘good’ many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse–next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient. Research problem: From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care? Research design: A critical qualitative approach was used, based on four focus group interviews. Participants: A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated. Ethical considerations: The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began. Findings and discussion: Two descriptive themes emerged from the inductive analysis: ‘A feeling of mistrust, control and rejection’ and ‘Being between hope and denial of next of kin and the desire of the patient to die when the time is up’. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses’ moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones. Conclusion: There is complex moral distress related to the nurse–next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care.

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Mitigating ethical conflict and moral distress in the care of patients on ECMO: impact of an automatic ethics consultation protocol

Journal of Medical Ethics ◽

10.1136/medethics-2020-106881 ◽

2021 ◽

pp. medethics-2020-106881

Author(s):

M Jeanne Wirpsa ◽

Louanne M Carabini ◽

Kathy Johnson Neely ◽

Camille Kroll ◽

Lucia D Wocial

Keyword(s):

Decision Making ◽

Moral Distress ◽

Ethics Consultation ◽

Outcome Data ◽

System Level ◽

Ethical Challenges ◽

Ethical Conflict ◽

Novel Therapy ◽

Intervention Protocol ◽

The Impact

AimsThis study evaluates a protocol for early, routine ethics consultation (EC) for patients on extracorporeal membrane oxygenation (ECMO) to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress.MethodsWe conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019 (n=68). Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers’ perceptions of the impact of the early intervention protocol.ResultsLimited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a ‘bridge to nowhere’, EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy.ConclusionData from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC—at least while this medical technology is in its nascent stages.

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Ethical challenges in care for older patients who resist help

Nursing Ethics ◽

10.1177/0969733014542672 ◽

2014 ◽

Vol 22 (6) ◽

pp. 631-641 ◽

Cited By ~ 7

Author(s):

Kari Brodtkorb ◽

Anne Valen-Sendstad Skisland ◽

Åshild Slettebø ◽

Ragnhild Skaar

Keyword(s):

Moral Distress ◽

Dental Treatment ◽

Academic Staff ◽

Research Question ◽

Healthcare Services ◽

Personal Hygiene ◽

Ethical Challenges ◽

Ethical Guidelines ◽

Moral Uncertainty ◽

Legal Competence

Background: Situations where patients resist necessary help can be professionally and ethically challenging for health professionals, and the risk of paternalism, abuse and coercion are present. Research question: The purpose of this study was to examine ethical challenges in situations where the patient resists healthcare. Research design: The method used was clinical application research. Academic staff and clinical co-researchers collaborated in a hermeneutical process to shed light on situations and create a basis for new action. Participants and research context: Four research groups were established. Each group consisted of six to eight clinical co-researchers, all employees with different health profession backgrounds and from different parts of the municipal healthcare services, and two scientific researchers. Ethical considerations: The study was conducted in compliance with ethical guidelines and principles. Participants were informed that participation was voluntary and that confidentiality would be maintained. They signed a consent form. Findings: The findings showed that the situations where patients opposed help related to personal hygiene, detention in an institution and medication associated with dental treatment. The situations were perceived as demanding and emotionally stressful for the clinicians. Discussion: The situations can be described as everyday ethics and are more characterised by moral uncertainty and moral distress than by being classic ethical dilemmas. Conclusion: Norwegian legislation governing the use of force seems to provide decision guidance with the potential to reduce uncertainty and moral stress if the clinicians’ legal competence had been greater.

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Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond

Journal of Medical Ethics ◽

10.1136/medethics-2020-106764 ◽

2021 ◽

pp. medethics-2020-106764 ◽

Cited By ~ 1

Author(s):

Janet Delgado ◽

Serena Siow ◽

Janet de Groot ◽

Brienne McLane ◽

Margot Hedlin

Keyword(s):

Communities Of Practice ◽

Moral Distress ◽

Ethical Challenges ◽

Ethical Practice ◽

Group Settings ◽

Healthcare Settings ◽

Mutual Engagement ◽

Starting Point ◽

Group Experiences ◽

Moral Resilience

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

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Ethical Challenges in Cancer Care: A Qualitative Analysis of Nurses' Perceptions

Research and Theory for Nursing Practice ◽

10.1891/1541-6577.33.2.169 ◽

2019 ◽

Vol 33 (2) ◽

pp. 169-182

Author(s):

Nasrin Rezaee ◽

Marjan Mardani-Hamooleh ◽

Mahnaz Ghaljeh

Keyword(s):

Cancer Patients ◽

Moral Distress ◽

Organizational Factors ◽

Communication Process ◽

Ethical Challenges ◽

Patients With Cancer ◽

Patient’S Autonomy ◽

Futile Care ◽

Healthcare Administrators ◽

Nurses Perceptions

Cancer is a growing problem in the world, meanwhile, the issue of providing care for cancer patients has been associated with multiple ethical challenges (ECs). This study aimed to investigate and explain the nurses' perceptions of ECs in caring for cancer patients in Iran. In this qualitative study, the participants consisted of 25 nurses working in cancer wards. The typical EC that the nurses are faced with while caring for cancer patients included categories such as “creating moral distresses” and “threat to patient's autonomy.” The category of creating moral distress consisted of two subcategories, including “faulty communication process” and “provision of futile care.” Also, the category of “threat to patient's autonomy” included subcategories of “individual factors” and “organizational factors.” Since disregarding ethical principles in caring for patients with cancer will result in greater ECs in this respect, the healthcare administrators should make more effort to help establish transparent rules, and develop protocols needed to identify and eliminate these ECs.

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