STRATEGIES FOR COPING WITH MORAL DISTRESS ADOPTED BY NURSES IN TERTIARY CARE: A SCOPING REVIEWABSTRACT
Objective: to map the scientific evidence on strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care.
Method: this is a Scoping Review based on the PRISMA-ScR recommendations. The searches were performed in September 2020 in the MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane and Biblioteca Virtual en Saúde databases. The eligibility criterion was to include studies that discussed strategies for coping with moral distress adopted by nurses in tertiary care, finding 2,041 studies, which were organized and screened in the Endnote software. The data were organized in Excel spreadsheets and analysis of the results was performed using the ATLAS.ti software.
Results: the final selected sample consisted of 23 studies, which were grouped in two axes: strategies and recommendations. Four articles were included in the “strategies” axis, which reported actions taken to face moral distress, detailing the intervention and their results. The others, included in the “recommendations” axis, are articles whose focus was the experience of moral distress, suggesting important aspects to face it.
Conclusion: recognition of moral distress by nurses and the opportunity for collective discussion and exchange of experiences are ways of collectively facing the situations. In addition, the institution's active participation in carrying out interventions was recommended. However, gaps were noticed in the production of studies that actually go deeper into intervention actions to cope with moral distress.
DESCRIPTORS: Nursing; Psychological adaptation; Psychological stress; Moral; Ethics in nursing; Hospital
RESUMEN
Objetivo: mapear las evidencias científicas sobre diversas estrategias para afrontar el sufrimiento moral adoptadas por enfermeros en el contexto de los servicios de salud en el nivel terciario de atención.
Método: Scoping Review basada en las recomendaciones PRISMA-ScR. Las búsquedas se realizaron en septiembre de 2020 en las siguientes bases de datos: MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane y Biblioteca Virtual de Saúde. El criterio de elegibilidad fue incluir estudios que debatieran estrategias para afrontar el sufrimiento moral adoptadas por los enfermeros en el nivel terciario de atención, con lo que se encontraron 2.041 estudios, que se organizaron y seleccionaron en el software Endnote. Los datos se organizaron en planillas de Excel y se realizó un análisis de los resultados con la ayuda del software ATLAS.ti.
Resultados: la muestra final seleccionada compuesta por 23 estudios, que fueron agrupados en dos ejes: estrategias y recomendaciones. Cuatro artículos se encuadraron en el eje de “estrategias”, y reportaron acciones adoptadas para afrontar el sufrimiento moral, detallando la intervención y sus resultados. Los demás, incluidos en el eje de “recomendaciones”, son artículos cuyo enfoque fue la experiencia del sufrimiento moral, con sugerencias relacionadas con aspectos importantes para afrontarlo.
Conclusión: el reconocimiento del sufrimiento moral por parte de los enfermeros y la oportunidad de debate colectivo e intercambio de experiencias son formas de afrontar las situaciones en forma colectiva. Además, se recomendó la participación activa de la institución al implementar las intervenciones. Sin embargo, se percibieron deficiencias en la producción de estudios que, de hecho, profundicen en acciones de intervención para afrontar el sufrimiento moral.
DESCRIPTORES: Enfermería; Adaptación psicológica; Estrés psicológico; Moral; Ética en enfermería; Hospital
RESUMO
Objetivo: mapear as evidências científicas sobre estratégias para o enfrentamento do sofrimento moral por enfermeiros no contexto dos serviços de saúde na atenção terciária.
Método: trata-se de uma Scoping Review com base nas recomendações PRISMA-ScR. As buscas foram realizadas em setembro de 2020 nas bases de dados MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane e Biblioteca Virtual de Saúde. O critério de elegibilidade foi incluir estudos que discutissem estratégias para o enfrentamento do sofrimento moral pelos enfermeiros na atenção terciária, encontrando assim 2.041 estudos, os quais foram organizados e triados no software Endnote. Os dados foram organizados em planilhas do Excel e uma análise dos resultados foi realizada mediante auxílio do software ATLAS.ti.
Resultados: a amostra final selecionada foi de 23 estudos, os quais foram agrupados em dois eixos: estratégias e recomendações. Quatro artigos foram enquadrados no eixo “estratégias”, os quais relataram ações realizadas para enfrentamento do sofrimento moral, detalhando a intervenção e os seus resultados. Os demais, incluídos no eixo “recomendações”, são artigos cujo enfoque foi a vivência do sofrimento moral, com sugestão de aspectos importantes para o seu enfrentamento.
Conclusão: o reconhecimento do sofrimento moral pelos enfermeiros e a oportunidade de discussão coletiva e troca de experiências são formas de enfrentar, coletivamente, as situações. Ademais, foi recomendado a participação ativa da instituição na realização de intervenções. Contudo, perceberam-se lacunas na produção de estudos que de fato aprofundam em ações de intervenções para o enfrentamento do sofrimento moral.
DESCRITORES: Enfermagem; Adaptação psicológica; Estresse psicológico; Moral; Ética em enfermagem; Hospital
INTRODUCTION
Moral Distress (MD) is a process that can be experienced when nurses are faced with a moral issue, make their judgment, but are unable to act in accordance with their values. In this case, the moral deliberation process is interrupted due to obstacles that prevent the ethical-moral position of the nurse facing the moral issue1.
The MD experience, due to the procedural nature and to its development over time, can lead nurses not to position themselves, which is characterized, by the authors, as “stagnation in uncertainty”1:412. This occurs when the professionals are not able to position themselves according to their ethical-moral values, to morally deliberate and advocate for the patient or to face the moral issue1, developing their practice in a mechanical and uncritical manner, producing invisibilities2.
Specifically in hospitals, the constant experience of moral issues that require the nurses' critical position is perceived. It is noted that the hospital scenario concentrates most of the publications on the theme1, in addition to being an environment permeated by moral issues2. However, it is not always possible for nurses to carry out practices consistent with their moral judgment, affecting quality of health care in these institutions. It is necessary to create ways for nurses to be able to recognize and deal with moral issues in their routine, acting in favor of their practice, that is, patient care2-3.
National and international studies have focused on analyzing the causes and effects of MD in nurses and state the importance of creating ways to deal with this situation in the researched scenarios1-2,4-7. However, it is fundamental to explore studies that assume interventions focused on coping strategies for MD in hospitals as a research object, given that they can generate positive impacts for the nurse, the institution and the patient.
Given the reality of the cause and effects of the MD experienced by nurses and the importance of coping with it in the hospital setting, the guiding question of this study arises: “which is the scientific evidence on the strategies for coping with MD adopted by nurses in the context of health services in tertiary care?”. This study is justified by the need to map surveys that promote initiatives to face MD, in order to promote the development of ethical practices consistent with the moral judgment of nurses in hospital institutions.
In view of the above, the objective of this study was to map the scientific evidence on strategies for coping with MD adopted by nurses in the context of health services in tertiary care.
METHOD
This is a scoping review, with its protocol registered in the Open Science Framework (OSF) (https://osf.io/962t7). This method allows mapping the main concepts, clarifying research areas and identifying knowledge gaps8, as is the case of intervention strategies for coping with MD.
This review was developed based on the PRISMA-ScR recommendations9 and on the method proposed by the Joanna Briggs Institute10, which establishes five stages: 1) identification of the research question; 2) identification of the relevant studies; 3) selection of the studies; 4) data analysis; and 5) data grouping, synthesis and presentation.
To identify the research question, the PCC strategy was used and, for the purposes of this study: P (Population) - Nurses; C (Concept) - Coping with moral distress; and C (Context) - Health services in tertiary care. Thus, the guiding question was as follows: “which is the scientific evidence on the strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care?”.
The study sample consisted of research studies related to coping strategies for MD adopted by nurses in different services in a hospital context, fully published in the Portuguese, Spanish and/or English languages until August 2020. Editorials, books, letters, monographs, dissertations, theses, blogs, theoretical and reflection articles were excluded.
The search was carried out in September 2020, in the following databases: MEDLINE®, National Library of Medicine (PubMed); Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (WoS), Cochrane, and Biblioteca Virtual de Saúde (BVS). The strategy adopted was devised with the librarian and the Boolean operators OR and AND were used for each item of the PCC strategy, as described in Chart 1.
The first stage of the review involved searching the databases, in which the articles were identified and exported to the EndNote® software. The studies identified had their titles and abstracts read and analyzed by six reviewers, who worked in pairs, to select the potential eligible articles. In case of disagreement regarding inclusion, a third reviewer performed the assessment.
In the second stage, all the studies included were read in full after development of the first stage by all the reviewers independently in order to answer the review question and extract the data of interest. For this stage, an Excel® software spreadsheet was used, prepared by the authors and organized considering the following variables: author, title, country, year of publication and level of evidence. The doubts generated were resolved by consensus among the authors10. Regarding the results, they were organized, analyzed and categorized using the ATLAS.ti software, version 9. The predefined thematic categories were the following: “strategies” and “recommendations”.
RESULTS
A total of 2,041 articles were identified in the databases and the final sample consisted of 23 studies, as shown in Figure 1.
Flowchart referring to the selection process of the Scoping Review studies, adapted from PRISMA-ScR10. Belo Horizonte, MG, Brazil, 2020.
The 23 articles included in this review were organized in a bibliographic chart presented in Chart 2, containing title of the article, country of origin, year of publication, type of study and level of evidence according to the study published in the American Journal of Nursing11.
As shown in Chart 2, the articles were grouped into two categories, namely: strategies (04 articles) and recommendations (19 articles).
Regarding the articles included in the “strategies” category, they reported actions taken to cope with MD, detailing the intervention, the evaluation modality and its results (Figure 2).
Regarding the types of strategies, the three emphasized development of the recognition of MD by the nurses and the opportunity for discussion and exchange of experiences among the participants, thus creating together ways to face the situation. In addition, it was noticed that, of the four interventions, three applied MD scales for pre- and post-action assessment. The institution's role in carrying out the interventions is highlighted, as it is responsible for their execution.
The articles included in the “recommendations” category, on the other hand, are those whose focus was the MD experience, and the coping strategies were only recommendations/suggestions, that is, there were no detailed interventions throughout the article. Among the coded recommendations/suggestions, it was noticed that 14 articles addressed the importance of spaces for discussion and exchange of experiences among the team16-17,20-23,25-29,31,34; nine addressed the team's collaboration in this coping16,17,19,22-25,33,34, the need for education and development of ethical skills17,20-24,27-29 and institutional and leadership support16,26-32,34; eight mentioned the implementation of moral strengthening programs and support for the ethical climate17,23-24,26-29,31,34; six dealt with the need for the professionals to recognize the causes of MD17-18,21,24,28-29; five disclosed the importance of promoting autonomy, self-reflection, self-awareness and self-confidence16-17,22,24-25; three mentioned welcoming and emotional support to the professionals in the face of MD16,24,26 and dealt with resilience and moral courage17,27,32; two discussed the construction of healthy work environments26,30 and the creation of programs for recreational activities/sports and spiritual support16-17; and one article referred to the influence of adequate staffing.
In general, the results showed that the intervention strategies adopted encompass the relevance of MD recognition for coping with it; the need to deal with the situation collectively, sharing experiences; and the importance of institutional responsibility in adopting measures to face MD.
DISCUSSION
MD recognition by nurses in the practice environment was the focus of the actions to cope with MD in the eligible studies. In the description of these actions, the concept and signs and symptoms of MD were addressed, as well as the barriers that prevent decision-making in consonance with the professionals' moral judgment and the exchange of experiences among the team members to deal with moral issues.
When outlining coping strategies, it becomes necessary that those who experience MD understand its concept. MD is triggered when the professionals are faced with a moral issue, make their moral judgment, but are prevented from making a decision due to barriers that can be influenced by gender, ethnicity, lack of time, organizational and institutional policies, work environment and the contradiction between the idealized practice and its performance in the work routine2,35. It is an individual moral experience, in which each professional experiences distress differently1.
When experiencing MD, the professional experiences a feeling of frustration, anguish, loss of autonomy and, thus, impotence to act, producing invisibilities2. Such invisibility distances nurses from their practice, causing identity ruptures, insecurities and loss of meaning, which may culminate in job abandonment2. Given such feelings, recognition of MD becomes necessary, which occurs through moral sensitivity, being the starting point for coping with it.
Moral sensitivity is an important skill for Nursing in making moral decisions and managing ethical problems in the different health care spaces36. Development of sensitivity can take place through ethical Nursing education, professional experience, clinical knowledge, dialog, relationship with the other members of the health team and professional autonomy3,36. Such components promote the construction of new moral skills that will assist these individuals in recognizing MD and its experience7. Thus, they will be able to objectively outline individual and collective strategies for coping with it.
Regarding the provision of collective spaces for coping with MD, the ethical discussion among those involved stands out as indispensable, where there is exposure of moral anguish, which is highly subjective, making it possible to map situations that are ethically challenging and potential generators of MD27. For this to occur, it becomes necessary for the individual to establish effective and horizontal communication with the team, providing opportunities for group analysis of the situations in order to contribute to decision-making in accordance with their moral judgment37-38.
The interventions in this review showed the importance of listening to the feelings and promoting mutual accountability for the decisions made in the workplace39. Through these actions, nurses feel welcomed and are able to develop individual and team action plans focused on self-care and professional empowerment, contributing to coping with MD12,15,40. Such actions can be developed in collective spaces, such as formal or informal meetings, in order to promote a safe and participatory environment for questions, reflections and analyses of everyday ethical situations, so that the workers can share experiences, feelings and knowledge3,40. In addition, the results of this review pointed to the conduction of meetings such as workshops, retreats and educational interventions in groups.
It is noteworthy that these spaces provide opportunities for discussions, dialog, exchange of experiences, sharing of knowledge and feelings and team collaboration. In this context, the collaborative practice is revealed, which is based on the interdisciplinary work that recognizes the role and knowledge of each professional within the team41. This practice promotes autonomy, trust, empowerment and better performance of activities, impacting on the optimization of the interprofessional relationships and shared decision-making among those involved39. This is because it encompasses an intense process of reflection and exchange of experience among the subjects, considering the moral judgment of each one. The collaborative practice reveals itself, then, as a powerful protective factor against the MD experiences, since it turns moral deliberation into a collective act39.
It is therefore understood that collaborative practice must be adopted as an institutional culture, in which the presence and support of leaders, horizontalized work relationships and integration between the different professionals are encouraged in order to create co-accountability among the actors involved by the processes faced in the work routine, including MD. It is important that collaborative practice is assumed as an institutional value, being a guide for the professionals' moral deliberation.
In this context, institutional responsibility in dealing with MD stands out. This research evidenced the importance of adopting institutional strategies that prioritize measures to deal with MD in the work environment, which promotes healthy work environments. A study conducted during the pandemic42 found that there is a reciprocal and bilateral relationship between MD and the dimensions of the Healthy Work Environment (HWE) proposed by the WHO41. This relationship is presented in how values underlying the two constructs are affected, with the possibility of compromising the structures of the work environment and the workers' well-being. And articulating them has the power to promote insights for interventions that protect the workers from MD experiences42.
Healthy work environment promotion programs help institutions protect and promote the health of their workforce, integrating health, safety and well-being into a process of constant improvements43, through a mutual commitment between workers and managers, in a collaborative manner41. Thus, the commitment to promoting healthy work environments includes concern with psychosocial and organizational aspects, such as organizational culture, attitudes, values, beliefs, spirituality and daily practices, which exert an influence on the workers' mental and physical well-being41 and, therefore, prevent MD experiences. On the other hand, mismatches between the management and organization practices negatively affect the workers' psychological, social and physical aspects44. In this sense, as a way of providing a healthy psychosocial environment and minimizing MD experiences, it is recommended to implement proper distribution and reduction of workload, provision of communication and leadership training for managers, zero tolerance for harassment and discrimination in the workplace, as well as a management style that promotes consultation, negotiations, reciprocal communication, constructive feedback and respectful performance management41,45.
It is reinforced that the interventions for coping with MD need to be incorporated as an institutional responsibility, providing, in addition to development of moral sensitivity for its recognition by the parties, individual and collective engagement in the deliberations involving moral issues in the routine practice of nurses in institutions and promotion of healthy work environments.
This study presents limitations referring to the descriptors defined in the search strategy. This is because there is no specific descriptor for “moral distress”, which represents low sensitivity in the search for studies that answered the research question. In this sense, many studies were identified and subsequently excluded in the screening stage for addressing issues such as mental distress and burnout. In addition, the absence of research studies with level of evidence I, systematic reviews or meta-analysis in the study sample is highlighted. However, this is justified due to the existing scientific gap and lack of intervention research studies aimed at coping with MD.
The contributions to the field of Nursing are based on the impact caused by MD on nurses, both personally and professionally. Thus, studies like this, which explore interventions for coping with MD in hospitals, encourage the adoption of actions that foster the development of ethical practices consistent with the nurses' moral judgment, favoring a healthy work environment and the quality of the Nursing care provided.
CONCLUSION
This study mapped the diverse scientific evidence on strategies for coping with MD adopted by nurses in the context of health services in tertiary care. The sample consisted of 23 studies that pointed out, among strategies and recommendations for coping with moral distress, the importance that such coping be carried out collectively by the team, highlighting the opportunity for meetings and spaces for discussion to exchange experiences that lead to the recognition of moral distress, its signs and symptoms and co-accountability between the parties involved and the institution in the process of coping with MD.
It is important to emphasize that, although the hospital context concentrates most of the publications about moral distress in the literature, we notice that, among the 23 studies, only 4 articles adopted interventions focused on coping strategies for MD in hospitals as research object; the rest (19 articles) focused on the MD experience, addressing recommendations/suggestions of relevant aspects in their work, not detailing any action in itself. Therefore, the scarcity of studies in the literature addressing intervention actions to cope with MD is highlighted, which is a suggestion for developing new studies in this area.
ACKNOWLEDGMENT
Universidade Federal de Minas Gerais (UFMG).
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Edited by
Publication Dates
-
Publication in this collection
11 Feb 2022 -
Date of issue
2022
History
-
Received
14 May 2021 -
Accepted
23 Sept 2021
