Article
Moral distress in nurses at an acute care hospital in Switzerland: Results of a pilot study
Nursing Ethics 2015, Vol. 22(1) 77–90 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014534875 nej.sagepub.com
Michael Kleinknecht-Dolf University Hospital Zurich, Switzerland
Irena Anna Frei University Hospital Basel, Switzerland
Elisabeth Spichiger University of Basel, Switzerland; Bern University Hospital (Inselspital), Switzerland
Marianne Mu¨ller Zurich University of Applied Sciences, Switzerland
Jacqueline S Martin University Hospital Basel, Switzerland
Rebecca Spirig University of Basel, Switzerland; University Hospital Zurich, Switzerland
Abstract Background: 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
Corresponding author: Rebecca Spirig, Department of Nursing and Allied Health Care Professions, University Hospital Zurich, Ra¨mistrasse 100, 8091 Zurich, Switzerland. Email: [email protected]
78
Nursing Ethics 22(1)
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. Keywords Acute care nurses, instrument development, moral distress
Introduction The results of several US-American studies suggest that the introduction of diagnosis-related groups (DRGs) and the associated financial constraints may bring about an increase in situations leading to moral distress among nurses.1–3 Moral distress can trigger emotional and physical reactions in nurses and can cause them to withdraw emotionally from patients. It can also lead them to change their work place or can even cause them to leave the nursing profession altogether.4–9 For our purposes, moral distress describes the burden experienced by nurses who believe they know the ethically appropriate course of action to take regarding nursing care, but feel constrained from taking that action. Jameton10 first described this phenomenon in 1984, with subsequent findings of studies leading to the further development of the concept.11 International studies have shown that the factors contributing to moral distress may be personal or contextual or may also arise out of clinical situations.12 Self-doubt and a lack of knowledge are personal factors that could possibly have an effect on moral distress. Possible contextual factors could be a lack of resources, inadequate interprofessional communication, or an imbalance of power between various professional groups. Clinical factors, such as unnecessary or futile treatments, or situations where patients and families are given false hope can also contribute to moral distress.8,13–16 Actually, no German publication could be found addressing moral distress as a concept or with a measurement instrument in German. However, moral distress has been mentioned in other contexts in several German publications, mainly in the realm of ethics. In these studies, the authors translated the term as ‘‘Moralischer Stress’’17–19 while others translate it as ‘‘Moralischer Distress.’’20,21 For the purposes of our study, we decided to translate moral distress into German as ‘‘Moralischer Stress.’’ In accordance with other authors, the emphasis is on the moral components inherent in the phenomenon of moral distress, rather than on the emotional reaction.11,22 International studies have shown that the perception of moral distress varies, depending on the particular discipline or profession in question. There may be variation in the significance of causative factors as well as in the manifestation of characteristics and symptoms.4,8,9 In addition, the concept is influenced by culture as well as by context.23–27 For this reason, it is not known whether moral distress has the same defining attributes in German-speaking countries as it has in other cultures. And, more specifically, it is unknown whether it has the same attributes in German-speaking Switzerland. As a result, there was no instrument available for use in measuring moral distress among nurses in German-speaking Switzerland. In light of the potentially substantial consequences of moral distress for healthcare professionals that have been shown in international studies, we were interested in a German-speaking instrument to assess moral distress by registered nurses (RNs) in Swiss acute care hospitals. Thus, the aim of this pilot study was to develop an instrument for measuring moral distress and to test the comprehensibility, feasibility, and effort associated with the collection of data, as well as to obtain initial indications of the instrument’s validity. 78
Kleinknecht-Dolf et al.
79
This pilot study was conducted within the nursing sciences subproject ‘‘Monitoring the impact of the DRG-payment system on nursing service context factors in Swiss acute care hospitals.’’28 The nursing sciences subproject is part of the research program ‘‘Impact of Diagnosis-Related Groups (DRGs) on patient care and professional practice’’ (IDoC), a large-scale multiprofessional mixed-methods evaluation study in Switzerland, investigating the impact of the introduction of SwissDRGs.29,30 In this article, we describe the development of the new instrument and present the results of our pilot study.
Methods Design The study was designed as a cross-sectional pilot survey to develop and test the newly developed moral distress instrument.
Participants and setting The study was conducted on eight units drawn from internal medicine, surgery, and intensive care at a single university hospital in German-speaking Switzerland. The units were chosen based on whether they offered a representative mix of specialty fields and patient populations in relation to the overall population of interest. Within these units, 294 RNs were eligible for participation. In addition to having a Swiss nursing diploma or foreign equivalent, the participants had to be engaged in direct care of patients.
Data collection In April 2011, nurses were mailed an information letter describing the goal of the survey and data collection procedures. This first letter instructed the nurses that they could provide informed consent by filling in the questionnaire. In a second letter, nurses were asked to fill out the web-based questionnaire within a month, using the online link provided. In order to support nurses, the project manager paid scheduled visits to the participating units and reported the current response rate of the online questionnaire. Concurrent with the pilot study, the nurses documented (via email or using a feedback form posted in the unit) any difficulties associated with filling out the questionnaire. Additionally, over the course of the month-long data collection, the project manager recorded verbal feedback received during regularly scheduled visits to the participating units.
Instrument development After an extensive literature search, the Moral Distress Scale developed by Hamric and Blackhall for intensive care nurses was chosen as the basis for our German-context instrument for acute care. This was based on the wide-spread acceptance of their theoretical framework and the level of development of the scale. Hamric and Blackhall’s scale is a revised version of Corley’s original questionnaire and consists of 19 items, which are to be answered on a 5-point Likert scale. The internal consistency measured by Cronbach’s alpha was 0.83.4,9,15 Three independent clinical nurse specialists, familiar with the theoretically based concept of moral distress and possessing long-standing first-hand experience in the intended field of application, conducted an initial test of face validity of this revised version of the English scale. Based on that, we selected 9 items for general acute care. This type of reduction has been undertaken in other studies in the past. For example, a study on moral distress among acute care nurses was conducted in the United States, in which 79
80
Nursing Ethics 22(1)
7 items of Hamric and Blackhall’s scale were selected.31 Another example is a Japanese version developed for use in psychiatric nursing in which 8 of the original scale items were eventually retained.25 Corley recommended the use of context-specific adaptations and Hamric and Blackhall also regarded them as a necessity.4,8 The 9 items selected were then translated into German by two nurses, both native speakers of German and fluent in English. Their translation was tested for conceptual and semantic consistency by two other nurses who are native speakers of English and fluent in German. It became apparent that specific phraseology would have to be adapted to the context of acute care nursing in Switzerland. Specific components had to be tested for their relevance regarding in terms of the extended practical use of the adapted questionnaire.32,33 A group of 10 nursing experts, with many years’ experience as RNs in clinical practice in the relevant field and who were from acute care units that would later participate in the main study, received an overview of the concept of moral distress from one of the researchers. Afterward, the nursing experts assessed the 9 finalized items regarding their applicability, semantic consistency, and comprehensibility. No further adaption was necessary. In our Moral Distress Scale, each item describes a potential moral distress–inducing situation. Using a 5-point Likert scale (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’), nurses indicate how often in the preceding 12 months they have experienced each situation and the level of disturbance associated with the event (0 ¼ ‘‘none,’’ 4 ¼ ‘‘very high’’). Even if they have not experienced a given situation, they indicate how disturbing it would be if it were to occur in their practice. During data analysis, an average value with a standard deviation (SD) and range can be derived from the responses of multiple nurses to each component.4,8 For the purposes of data collection and in accordance with Corley’s approach, a definition of moral distress was provided with the questionnaire.4 This was to impart a better understanding of the phenomenon, given that it is currently not an established concept in the Swiss nursing environment. According to the definition, the experience of moral distress is linked to a nurse’s professional ethical principles. These principles may provide the foundation upon which decisions are made regarding which course of action is best and which procedures are in the patient’s best interest. If constraints inherent in the situation prevent the nurse from acting in accordance with his or her moral judgment, the nurse will experience moral distress.34 In light of this, it would be worthwhile to recognize the significance of professional ethical principles in the day-to-day practice environment. This would improve the ability to gauge the extent to which conditions and situations have the potential to trigger moral distress. In order to garner a response to this, an additional item was added to the questionnaire in which nurses were asked about the role of professional ethical principles in decisions about care. The professional ethical principles referenced here originate from the Swiss Association of Nurses.35,36 To support nurses’ understanding of the item, the definition referenced above was provided with the questionnaire. This item was also measured on a 5-point Likert scale (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’) for the frequency with which the nurse relied on professional ethical principles when making decisions regarding patient care. The resulting questionnaire comprised 10 items and was designed to be filled in by the study participants electronically. The administration of the survey was designed according to the procedures outlined in the guidelines for Good Clinical Practice. It was accessible by means of individual registration via any personal computer connected to the Internet.37 Corley’s original format for the Moral Distress Scale served as a template for the questionnaire. Due to technical restrictions, the qualities of ‘‘frequency’’ and ‘‘level of disturbance’’ had to be re-formatted in two rows, meaning that for each item, frequency had to be entered in the upper row while the estimated level of disturbance was entered in the lower row. The nurses were able to fill out the survey during working hours. The nurses documented any difficulties they had using or understanding the questionnaire and the associated online collection of personal data concurrently with completing the pilot questionnaire. 80
Kleinknecht-Dolf et al.
81
Data analysis A descriptive analysis of data was carried out. The analysis of the occurrence of missing data indicated instances where a questionnaire item may have been unclear or ambiguous. More advanced statistical analyses of the psychometric qualities of the questionnaire will take place once the first cross-sectional data collected under the nursing sub-study have been generated. In order to prove the face validity of the results, they were discussed with a sample of participants of the pilot study for verification regarding the situations they experienced. Based on the definition of moral distress as provided to them, the clinical nurse specialist responsible for a particular practice area gave a subjective overall assessment of moral distress (high/moderate/low) regarding the anticipated results. In addition, the distribution of calculated mean values relating to specific questionnaire responses was compared to previous studies. The analysis was conducted using SPSS for Windows, Version 19.
Ethical considerations The study proposal was approved by the cantonal ethics committee. All nurses invited to participate in the survey were first informed of the background and aim of the study by one of researchers. They were also advised that their participation was voluntary and that personal data would be used only in pseudonymized form. All participating nurses provided informed consent for the interviews online and were assured of data confidentiality. The participating nurses could opt out of the questionnaire at any time by clicking on the corresponding item ‘‘I do not want to continue filling out and/or do not want to complete the questionnaire.’’
Results Response rate The online questionnaire on moral distress was filled in by 160 RNs, resulting in a response rate of 55%. Among the various units, as few as 6 and as many as 38 nurses participated. The response rate ranged from 24% to 90%.
Work characteristics of the respondents Of the 160 RNs participating, 123 (76%) had been working in their unit for longer than 1 year at the time of the survey, and 142 (88%) were either employed full-time or working over 50% of full-time hours.
Missing data Of the 160 RNs, there were 11 participants who intentionally did not answer all of the questions regarding moral distress. This led to 46 missings occurring, giving an overall missing rate of 1.5%. Within the dimensions frequency or level of disturbance, no item carried a missing response number of greater than 8 (5%). The number of questions left unanswered was higher for questions pertaining to the level of disturbance (n ¼ 37, distributed over all 9 items) than for questions describing frequency (n ¼ 9, distributed over 6 items). In the nine instances where questions regarding frequency were not answered, questions regarding the level of disturbance were also left unanswered. Of the 149 participants who had agreed to fill out the questionnaire completely, there were three missings in the item responses. These missings were not replaced. 81
82
Nursing Ethics 22(1)
Range of answers The responses to the item in which participants were asked to assess the relevance of professional ethical principles ranged from 1 to 4 (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’). The responses to the items for the assessment of moral distress, including frequency and level of disturbance, ranged between 0 (‘‘never’’ or ‘‘none’’) and 4 (‘‘very often’’ or ‘‘very high’’). It is noteworthy that all participants indicated that they had, at least on one occasion (value ‘‘frequency’’ ¼ 1), experienced a moral distress–inducing situation and that they experienced this at minimum as a mild disturbance (value ‘‘level of disturbance’’ ¼ 1).
Proportions of answers The item questioning how often professional ethical principles play a role in everyday nursing decisions was answered with a mean of 3.36 (SD ¼ 0.69); no one answered that professional ethical principles never play a role in everyday nursing decisions. The four situations having the potential to trigger moral distress that were found to occur most often were ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (M ¼ 2.40, SD ¼ 0.96), ‘‘work with levels of nurse or other care provider staffing that I consider unsafe’’ (M ¼ 1.94, SD ¼ 1.29), ‘‘watch patient care suffer because of a lack of provider continuity’’ (M ¼ 1.93, SD ¼ 0.92), and ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (M ¼ 1.80, SD ¼ 1.07). Interestingly, the four situations perceived as being the most disturbing were the same, but in a different order: ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (M ¼ 2.34, SD ¼ 1.09), ‘‘work with levels of nurse or other care provider staffing that I consider unsafe’’ (M ¼ 2.33, SD ¼ 1.38), ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (M ¼ 2.30, SD ¼ 1.19), and ‘‘watch patient care suffer because of a lack of provider continuity’’ (M ¼ 2.13, SD ¼ 1.12). The results of the entire questionnaire are shown in detail in Table 1; the frequency and levels of disturbance of these 4 items are represented graphically in Figure 1.
Feedback from nurses regarding the comprehensibility, feasibility, and effort associated with the collection of data Most participants found the questionnaire comprehensible. Some criticized the phraseology of certain statements as overly convoluted or too complicated. Another criticism was directed at the double negatives contained in some statements. One unit leader found that the questionnaire was only practicable for leaders working mainly in day-to-day nursing practice and not as much for those involved in unit management. The feedback of nurses regarding the feasibility and the effort associated with the collection of data were ambivalent. The electronic format of the questionnaire generally received very positive comments as well as the fact that it could be completed by accessing any Internet browser. While going through the online registration process, designed according to the procedures outlined in the guidelines for Good Clinical Practice, participants criticized the process as being too complicated. In spite of their interest in taking part, this deterred some from participating and filling in the questionnaire. Given that the questionnaire takes about 5 min to complete, these potential participants found a registration process (prior to online access), that took nearly as long to complete as the questionnaire itself, to be too time consuming.
Feedback from nurses regarding the results Some of the nurses who had taken part in the pilot study attended a presentation and discussion of the results held at each department. They confirmed that the results reflect their subjective assessment of conditions in 82
83
Professional ethical principles 1. I rely on professional 159 ethical principles when making decisions regarding patient care. Moral distress 158 1. Provide less than optimal care due to pressures from administrators or insurers to reduce costs. 159 2. Witness healthcare providers giving ‘‘false hope’’ to a patient or family. 159 3. Carry out the physician’s orders for what I consider to be unnecessary tests and treatments. 157 4. Avoid taking action when I learn that a physician or nurse colleague has made a medical error and does not report it.
N
49 54 (30.8%) (34%)
27 56 54 (17.0%) (35.2%) (34.0%)
45 24 (28.7%) (15.3%)
24 (15.1%)
2 (1.3%)
79 (50.3%)
6 (3.8%)
22 (13.8%)
49 50 33 (31.0%) (31.6%) (20.9%)
3
17 (10.8%)
2
2 13 70 (1.3%) (8.2%) (44.0%)
1
0 (0.0%)
0 (¼ never)
3 (1.9%)
20 (12.6%)
10 (6.3%)
9 (5.6%)
74 (46.5%)
.69
–
n
.78
2.40
.97 154
.96 156
1.65 1.09 155
1.80 1.07 152
3.36
4 (¼ very often) Mean SD
Proportion of answers over scale, n (%)
Frequency
39 (25.3%)
9 (5.8%)
23 (14.8%)
14 (9.2%)
–
0 (¼ none) –
2
26 37 (16.9%) (24.0%)
26 46 (16.7%) (29.5%)
30 30 (19.4%) (19.4%)
25 39 (16.4%) (25.7%)
–
1
–
–
–
Mean SD
22 2.34 1.09 (14.1%)
(continued)
31 21 1.80 1.38 (20.1%) (13.6%)
53 (34%)
46 26 2.14 1.32 (29.7%) (16.8%)
50 24 2.30 1.19 (32.9%) (15.8%)
–
3
4 (¼ very high)
Proportion of answers over scale, n (%)
Level of disturbance
Table 1. Frequency and level of disturbance of the items on professional ethical principles and the items on moral distress.a
84 73 (45.9%) 22 (13.8%)
112 (70.0%) 8 (5.0%) 26 (16.3%)
160
160
160
160
0 (¼ never)
159
N
Frequency
2 0 (0.0%)
3
1 (0.6%)
38 36 39 (23.8%) (22.5%) (24.4%)
45 63 39 (28.1%) (39.4%) (24.4%)
33 11 (20.6%) (6.9%)
78 41 17 (48.8%) (25.6%) (10.6%)
71 14 (44.7%) (8.8%)
1
21 (13.1%)
5 (3.1%)
3 (1.9%)
2 (1.3%)
1 (0.6%)
.92 158
.81 158
.90 157
.70 155
n
1.94 1.29 158
1.93
.44
1.37
.65
4 (¼ very often) Mean SD
Proportion of answers over scale, n (%)
SD: standard deviation. a German items were translated for this publication.
5. Be required to care for patients I don’t feel qualified to care for. 6. Work with nurses or other healthcare providers who are not as competent as patient care requires. 7. Ignore situations of suspected patient abuse by caregivers. 8. Watch patient care suffer because of a lack of provider continuity. 9. Work with levels of nurse or other care provider staffing that I consider unsafe.
Table 1. (continued)
22 (13.9%)
14 (8.9%)
64 (40.5%)
19 (12.1%)
58 (37.4%)
0 (¼ none)
2
Mean SD
57 16 2.11 1.21 (36.3%) (10.2%)
28 19 1.48 1.45 (18.1%) (12.3%)
3
23 36 (14.6%) (22.8%)
32 47 (20.3%) (29.7%)
2.13 1.12
35 42 2.33 1.38 (22.2%) (26.6%)
49 16 (31.0%) (10.1)
15 24 23 14.6%) 32 1.65 1.60 (9.5%) (15.2%) (20.3%)
33 32 (21.0%) (20.4%)
30 20 (19.4%) (12.9%)
1
4 (¼ very high)
Proportion of answers over scale, n (%)
Level of disturbance
Kleinknecht-Dolf et al.
85
Figure 1. Stacked bar plots of (a) the most frequent and (b) the most disturbing items of the Moral Distress Scale.
their practice environment and their experience of moral distress. For each item, the response was illustrated with specific examples consistent with the results from the practice environment. For example, it was confirmed that patients were regularly discharged or transferred too early due to insufficient reimbursement or because of the need to clear beds for new patients. Nurses reported having to carry out physician-ordered tests or treatments that seemed to them to be unjustified and therefore unnecessary. This situation was often preceded by a lack of interprofessional communication so that the nurses were unaware of the reasoning behind a particular medical approach. Additionally, treatment plans in certain instances were not followed consistently, for whatever reason, leading the nurses to question their validity. The lack of continuity reported to be rife among nursing and medical personnel was regarded as potentially detrimental to the quality of treatment and care. Continuity of treatment and care were assessed as insufficient or inadequate (depending on the situation) when the implementation of primary nursing encountered organizational boundaries. Substitutions, caused by staff training and the rotation schedule of physicians, also had an effect. The insufficient staff coverage assessed by more than one-third of the nurses as frequent or very frequent can be accounted for by several notices to quit, in combination with difficulties in recruitment at the time of data collection. None of the nurses taking part in the evaluation of the results criticized the response format as being inadequate or as presenting a barrier to submitting their assessment properly. The nurses accounted for the varying levels of disturbance experienced in different moral distress– inducing situations by explaining that the experience of distress is dependent not only on the frequency with which the incident occurs but also on the effect a particular incident has on the patient or on a particular nurse. The comparison of the results with the estimates regarding moral distress in the units given by the clinical nurse specialists responsible for those units shows that on six of the eight units in question, their estimates corresponded in general with the overall results. Regarding the other two units, the clinical nurse specialist responsible for one unit estimated the collective stress level of the entire responses as too low, and in the case of the other unit, the estimate of the clinical nurse specialist was too high. 85
86
Nursing Ethics 22(1)
Discussion The aim of this pilot study was to examine the comprehensibility, the manageability, and the effort associated with a questionnaire on moral distress newly developed for the German-speaking context. The response rate of 55% for the study, which was designed as a web-based (online) survey, is in accordance with the response rate usual for such surveys.38 However, although each unit voluntarily registered to participate and had the same information regarding the survey, participation nevertheless varied considerably. That this was due to internal conditions on the units was subsequently confirmed in the evaluation discussions. On the unit with the highest response rate, the nurse manager and the clinical nurse specialists issued daily reminders of the survey during the change-of-shift report throughout the data collection period. This was to remind the nurses of the study in the midst of the hectic of the work day so that it would not be forgotten. In the process, no pressure was exerted on the nurses, and there was no tracking of who filled out the survey. The unit with the lowest response rate was experiencing a period of upheaval with high staff turnover. This may highlight the importance of appropriate on-site support for online surveys. Due to the relatively low response rate of certain units, no unit-specific sub-analyses could be carried out. Unfortunately, the lack of an equivalent control group means that the extent to which the online survey influenced the response behavior of the nurses cannot be determined. The literature is not in agreement in this regard, with certain studies showing no disparities in the response behaviors,39 while other authors found corresponding differences.40 However, what is known is that the format of the questionnaire also influences response behavior in online surveys. In the case of this pilot study, the questionnaire had to be re-formatted; the two parallel columns for entering answers regarding frequency and disturbance had to be converted to two horizontal parallel rows. These changes may have affected the response behavior and, as a result, the reliability and validity of the questionnaire as well.41,42 The relatively low number of missings is encouraging, with three missings from the total of 149 nurses who had agreed to complete the questionnaire in full. Based on the high proportion of fully completed questionnaires, it may well be concluded that these particular participants overlooked the items in question and that the failure to complete the survey in full was not due to an ambiguous formulation of the item. This interpretation is supported by fact that in each instance, one of the two dimensions (either frequency or disturbance) was answered. Unfortunately, it is not known why 11 participants did not wish to complete the questionnaire in full. It is possible that they found the formulation of the items to be too complicated, or that the questions regarding disturbance were more difficult to answer than those pertaining to frequency. Or possibly the participants did not realize that they could also give a hypothetical answer in those instances where they indicated a frequency of 0. Given the feedback from the participating nurses, an attempt needs to be made during the further development of the scale to come up with a simpler and more practice-focused formulation of the items. It is unfortunate that an unknown number of the nurses invited to participate declined to fill out the questionnaire due to the effort associated with the application procedure. For this reason, we need to simplify the application procedure while continuing to comply with the Guidelines for Good Clinical Practice.37 The results highlight the significant role of professional ethical principles in nurses’ day-to-day practice environment. Their prominence illustrates the importance of taking professional ethical principles into account in discussions regarding the role of nursing in the interprofessional treatment process as well as in efforts to avoid or reduce moral distress.43,44 The results also demonstrate that each of the statements regarding potentially moral distress–inducing situations set out in the questionnaire had relevance for the nurses in the practice environment, albeit with variations in frequency and in the intensity of disturbance experienced. The specific narratives (regarding patient or unit-related situations) related by the participating nurses during the evaluation discussions also demonstrated that the nurses had correctly understood the intended meaning of the statements. Moreover, 86
Kleinknecht-Dolf et al.
87
none of the participating nurses reported being unable to give the assessment due to a potential response not being offered. This indicates that the questionnaire’s answer scale appears to cover the required spectrum of occurrences encountered in the nurses’ practice environment and that the answer scale is distributed (albeit skewed) over all answer categories. In some of the earlier studies involving nurses in similar settings, a total score for the characteristics of frequency and disturbance was calculated by combining the scores of the individual items for these categories.45,46 In this study, this approach was not taken. The discussion of the results with the participants showed that frequency and disturbance (in the context of potential moral distress–inducing situations) were assessed in relation to the impact they have on patients and nurses. For this reason, the values of individual items are not comparable and consequently should not be added up to a total score. Moreover, this study shows that a more frequent occurrence of certain situations does not necessarily correlate with a correspondingly higher perceived level of disturbance. This is shown in the results themselves. For example, in that the frequency of occurrence for Item 3 (‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’), with a median value of 2.4, received a higher estimation than the frequency of occurrence for Item 1 (‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’) which had a median value of 1.80. Nonetheless, the level of disturbance experienced associated with both situations appears to be roughly comparable (Item 1: M ¼ 2.30 and Item 3: M ¼ 2.34). In subsequent discussions of the results with the nurses, they reported that in some situations, a certain adaptation or even resignation takes place and that the perception of disturbance is not heightened. For example, in the situation where nurses carry out physician-ordered tests or treatments, they deem to be unnecessary (Item 3). This indicates that an increase in the occurrence of moral distress–inducing situations does not necessarily have to lead to a heightened sense of disturbance. For this reason, the decision was taken not to form one product out of the values for frequency and those for level of disturbance as was done, to a certain extent, in other studies on moral distress.8 The frequency and level of disturbance associated with potentially moral distress–inducing situations need to be examined in a more differentiated manner. A comparison of the results of this study with those from earlier studies shows that the two items ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (Item 3) and ‘‘work with levels of nurse provider staffing that I consider unsafe’’ (Item 9) are also among those items with the highest values.1,2,4,47 Comparisons with the aforementioned studies are limited by the fact that not only different versions of the Moral Distress Scale developed by Corley15 in 1995 were used but also that these differed in the number of items and in the characteristics of the answer scale. Rather, they are also limited regarding diverse modes of calculation. In this respect, the extent to which such comparisons can be carried out is limited. It must also be taken into account that moral distress and the situations that may induce it are situationally and culturally specific phenomena.8,23,26 This may also explain why the items ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (Item 1) and ‘‘watch patient care suffer because of a lack of provider continuity’’ (Item 8), which in this study were rated relatively highly as regards frequency and disturbance, were rated lower in the studies mentioned above. Within the context of this pilot study, the selected items, generated from Corley’s Moral Distress Scale as well as expert opinions and discussions, were shown to be clinically relevant. In addition, they illustrate the frequency and degree of the associated disturbance experienced by the nurses who are affected. This can be understood to be an indication of the face validity of the present questionnaire as well as an initial indication of its construct validity. However, there was no examination of whether, in addition to the statements given, there were other situations relevant to the experience of moral distress. It is conceivable that there are situations in Swiss hospitals that would not have relevance in other settings and, as a result, were not recorded in our Moral Distress Scale. In light of the potentially substantial consequences of moral distress for healthcare professionals that have been shown in international studies, we introduced moral distress as a new concept in our preliminary 87
88
Nursing Ethics 22(1)
monitoring model of the mentioned study ‘‘Monitoring the impact of the DRG-payment system on nursing service context factors in Swiss acute care hospitals.’’28 Currently, there is also a lack of evidence regarding the relationship between moral distress and quality of care, indicating a need for further research in the field of nursing.12,48 We hope, with the results of our monitoring model, we will also contribute new knowledge to this question.
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 DRGs. Given the significance of professional ethical principles in day-to-day nursing practice, these results could serve as early indicators in intraprofessional as well as interprofessional discussions on collaboration between nurses and physicians regarding the prevention or reduction of moral distress. On the basis of these initial results, there needs to be a deeper examination of the concept of moral distress in the context of Swiss–German acute care hospitals and the questionnaire must be refined accordingly. The clarity of formulation and the discrimination between the items must be improved in order to facilitate the interpretation of results. Now that the relevance of all of the statements collected is known, the psychometric properties of the present questionnaire will have to be examined more deeply as well as its completeness regarding potential distress-inducing situations. The majority of the target user group seemed to find the questionnaire manageable and comprehensible. In order to improve the acceptance of the questionnaire, improvements to the wording will have to be made, and the administrative effort associated with filling it out online will have to be optimized. Acknowledgments Ethics committee and reference number: Kantonale Ethikkommission Zu¨rich, Stampfenbachstrasse 121, CH 8090 Zu¨rich; reference number: KEK-ZH-NR: 2011-0091. Conflict of interest The authors report no conflicts of interest. Funding The study was funded by the Swiss National Science Foundation, Ka¨the-Zingg-Schwichtenberg Foundation, Gottfried and Julia Bangerter-Rhyner Foundation, and the Olga Mayenfisch Foundation. References 1. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics 2007; 14(3): 344–359 (PMID: 17459818). 2. Elpern EH, Covert B and Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005; 14(6): 523–530. 3. Rice EM, Rady MY, Hamric AB, et al. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. J Nurs Manag 2008; 16(3): 360–373 (PMID: 18324996). 4. Corley MC, Elswick RK, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001; 33(2): 250–256 (PMID: 11168709). 5. Hamric AB, Davis WS and Childress MD. Moral distress in health care professionals. Pharos Alpha Omega Alpha Honor Med Soc 2006; 69(1): 16–23. 6. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum 1987–1988; 23(1): 16–29. 88
Kleinknecht-Dolf et al.
89
7. Gutierrez KM. Critical care nurses’ perceptions of and responses to moral distress. Dimens Crit Care Nurs 2005; 24(5): 229–241. 8. Hamric AB, Borchers CT and Epstein EG. Development and testing of an instrument to measure moral distress in health care professionals. AJOB Prim Res 2012; 3(2): 1–9. 9. Hamric AB and Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 2007; 35(2): 422–429. 10. Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984. 11. Lu¨tze´n K and Kvist BE. Moral distress: a comparative analysis of theoretical understandings and inter-related concepts. HEC Forum 2012; 24(1): 13–25. 12. Hamric AB. Empirical research on moral distress: issues, challenges, and opportunities. HEC Forum 2012; 24(1): 39–49. 13. Ka¨lvemark S, Hoglund AT, Hansson MG, et al. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med 2004; 58(6): 1075–1084 (PMID: 14723903). 14. Sile´n M, Svantesson M, Kjellstro¨m S, et al. Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability. J Clin Nurs 2011; 20: 3483–3493. 15. Corley MC. Moral distress of critical care nurses. Am J Crit Care 1995; 4(4): 280–285. 16. Papathanassoglou EDE, Karanikola MNK, Kalafati M, et al. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care 2012; 21(2): e41–e52. 17. Lauxen O. Moralische Probleme in der ambulanten Pflege—eine deskriptive pflegeethische Untersuchung. [Moral problems in home health care–a descriptive ethical study]. Pflege 2009; 22(6): 421–430. 18. Tewes R. Moralische Intelligenz: wertorientierte Fu¨hrung zahlt sich aus [Moral Intelligence: value-based management pays for itself]. In: Tewes R (ed.) Fu¨hrungskompetenz ist lernbar [Leadership can be learned]. 2. Auflage ed. Berlin, Heidelberg: Springer, 2011, pp. 47–60. 19. Zimmermann P, Jacobs H and Kowalski JT. ISAF und die Seele—zwischen Scha¨digung und Wachstum [ISAF and the soul - between damage and growth]. In: Seiffert A, Langer PC and Pietsch C (eds) Der Einsatz der Bundeswehr in Afghanistan [Deployment of the German military in Afghanistan]. Berlin, Heidelberg: Springer, 2012, pp. 143–152. ¨ bertherapie am Lebensende? Gru¨nde fu¨r ausbleibende 20. Albisser Schleger H, Pargger H and Reiter-Theil S. ‘‘Futility’’—U 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 fu¨r Palliativmedizin 2008; 9: 67–75. 21. Nienhaus A, Westermann C and Kuhnert S. Burn-out bei Bescha¨ftigten in der stationa¨ren Altenpflege und in der Geriatrie [Burnout among elderly care staff. A review of its prevalence]. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 2012; 55(2): 211–222. 22. Lu¨tze´n K, Cronqvist A, Magnusson A, et al. Moral stress: synthesis of a concept. Nurs Ethics 2003; 10(3): 312–322. 23. Mashiach Eizenberg M, Desivilya HS and Hirschfeld MJ. Moral distress questionnaire for clinical nurses: instrument development. J Adv Nurs 2009; 65(4): 885–892. 24. Lazzarin M, Biondi A and Di Mauro S. Moral distress in nurses in oncology and haematology units. Nurs Ethics 2012; 19(2): 183–195. 25. Ohnishi K, Ohgushi Y, Nakano M, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics 2010; 17(6): 726–740. 26. Harrowing JN and Mill J. Moral distress among Ugandan nurses providing HIV care: a critical ethnography. Int J Nurs Stud 2010; 47: 723–731. 27. Piers RD, Van den Eynde M, Steeman E, et al. End-of-life care of the geriatric patient and nurses’ moral distress. J Am Med Dir Assoc 2012; 13: 80.e7–80.e13. 28. Spirig R, Spichiger E, Martin JS, et al. Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals. Ger Med Sci 2014; 12: Doc07. 29. SwissDRG AG. Fallpauschalen in Schweizer Spita¨lern, Basisinformationen fu¨r Gesundheitsfachleute [Case-based prospective payment systems in Swiss hospitals, basic information for health care professionals]. Bern: SwissDRG AG, 2010. 89
90
Nursing Ethics 22(1)
30. Biller-Andorno N and Wild V. Impact of Diagnosis Related Groups (DRGs) on patient care and professional practice (IDoC): Universita¨t Zu¨rich—Ethik-Zentrum—Institut fu¨r Biomedizinische Ethik, http://www.ethik.uzh.ch/ ibme/forschung/drg.html (2010, accessed 5 February 2013). 31. Lawrence LA. Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nurs Forum 2011; 46(4): 256–268. ¨ bersetzung32. Martin JS, Vincenzi C and Spirig R. Prinzipien und Methoden einer wissenschaftlich akkuraten U spraxis von Instrumenten fu¨r Forschung und direkte Pflege [Principles and methods of good practice for the translation process for instruments of nursing research and nursing practice]. Pflege 2007; 20(3): 157–163. 33. Jones PS, Lee JW, Phillips LR, et al. An adaptation of Brislin’s translation model for cross-cultural research. Nurs Res 2001; 50(5): 300–304 (PMID: 11570715). 34. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650 (PMID: 12450000). 35. Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner SBK. Ethik in der Pflegepraxis [Ethics in nursing practice]. Bern: Zentralsekretariat SBK, 2003. 36. Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner SBK. Ethische Standpunkte 2, Verantwortung und Pflegequalita¨t [Ethical viewpoints 2, accountability and quality of care]. Bern: Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner, 2007. 37. Guideline for good clinical practice E6(R1), 1996, http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/ Guidelines/Efficacy/E6_R1/Step4/E6_R1__Guideline.pdf 38. Kongsved SM, Basnov M, Holm-Christensen K, et al. Response rate and completeness of questionnaires: a randomized study of internet versus paper-and-pencil versions. J Med Internet Res 2007; 9(3): e25. 39. Brock RL, Barry RA, Lawrence E, et al. Internet administration of paper-and-pencil questionnaires used in couple research: assessing Psychometric Equivalence. Assessment 2012; 19(2): 226–242. 40. Whitehead L. Methodological issues in internet-mediated research: a randomized comparison of internet versus mailed questionnaires. J Med Internet Res 2011; 13(4): e109. 41. Dillman DA and Christian LM. Survey mode as a source of instability in responses across surveys. Field Method 2005; 17(1): 30–52. 42. Van Schaik P and Ling J. Design parameters of rating scales for web sites. ACM Trans Comput Hum Interact 2007; 14(1): 1–35. 43. Cribb A. Integrity at work: managing routine moral stress in professional roles. Nurs Philos 2011; 12: 119–127. 44. Cronqvist A, Theorell T, Burns T, et al. Caring about—caring for: moral obligations and work responsibilities in intensive care nursing. Nurs Ethics 2004; 11(1): 63–76. 45. Meltzer LS and Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004; 13(3): 202–208. 46. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: development of a web-based survey. Acad Med 2010; 85(1): 111–117. 47. Pauly B, Varcoe C, Storch J, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573 (PMID: 19671643). 48. Schluter J, Winch S, Holzhauser K, et al. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304–321 (PMID: 18388166).
90
Moral distress in nurses at an acute care hospital in Switzerland: Results of a pilot study
Nursing Ethics 2015, Vol. 22(1) 77–90 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014534875 nej.sagepub.com
Michael Kleinknecht-Dolf University Hospital Zurich, Switzerland
Irena Anna Frei University Hospital Basel, Switzerland
Elisabeth Spichiger University of Basel, Switzerland; Bern University Hospital (Inselspital), Switzerland
Marianne Mu¨ller Zurich University of Applied Sciences, Switzerland
Jacqueline S Martin University Hospital Basel, Switzerland
Rebecca Spirig University of Basel, Switzerland; University Hospital Zurich, Switzerland
Abstract Background: 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
Corresponding author: Rebecca Spirig, Department of Nursing and Allied Health Care Professions, University Hospital Zurich, Ra¨mistrasse 100, 8091 Zurich, Switzerland. Email: [email protected]
78
Nursing Ethics 22(1)
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. Keywords Acute care nurses, instrument development, moral distress
Introduction The results of several US-American studies suggest that the introduction of diagnosis-related groups (DRGs) and the associated financial constraints may bring about an increase in situations leading to moral distress among nurses.1–3 Moral distress can trigger emotional and physical reactions in nurses and can cause them to withdraw emotionally from patients. It can also lead them to change their work place or can even cause them to leave the nursing profession altogether.4–9 For our purposes, moral distress describes the burden experienced by nurses who believe they know the ethically appropriate course of action to take regarding nursing care, but feel constrained from taking that action. Jameton10 first described this phenomenon in 1984, with subsequent findings of studies leading to the further development of the concept.11 International studies have shown that the factors contributing to moral distress may be personal or contextual or may also arise out of clinical situations.12 Self-doubt and a lack of knowledge are personal factors that could possibly have an effect on moral distress. Possible contextual factors could be a lack of resources, inadequate interprofessional communication, or an imbalance of power between various professional groups. Clinical factors, such as unnecessary or futile treatments, or situations where patients and families are given false hope can also contribute to moral distress.8,13–16 Actually, no German publication could be found addressing moral distress as a concept or with a measurement instrument in German. However, moral distress has been mentioned in other contexts in several German publications, mainly in the realm of ethics. In these studies, the authors translated the term as ‘‘Moralischer Stress’’17–19 while others translate it as ‘‘Moralischer Distress.’’20,21 For the purposes of our study, we decided to translate moral distress into German as ‘‘Moralischer Stress.’’ In accordance with other authors, the emphasis is on the moral components inherent in the phenomenon of moral distress, rather than on the emotional reaction.11,22 International studies have shown that the perception of moral distress varies, depending on the particular discipline or profession in question. There may be variation in the significance of causative factors as well as in the manifestation of characteristics and symptoms.4,8,9 In addition, the concept is influenced by culture as well as by context.23–27 For this reason, it is not known whether moral distress has the same defining attributes in German-speaking countries as it has in other cultures. And, more specifically, it is unknown whether it has the same attributes in German-speaking Switzerland. As a result, there was no instrument available for use in measuring moral distress among nurses in German-speaking Switzerland. In light of the potentially substantial consequences of moral distress for healthcare professionals that have been shown in international studies, we were interested in a German-speaking instrument to assess moral distress by registered nurses (RNs) in Swiss acute care hospitals. Thus, the aim of this pilot study was to develop an instrument for measuring moral distress and to test the comprehensibility, feasibility, and effort associated with the collection of data, as well as to obtain initial indications of the instrument’s validity. 78
Kleinknecht-Dolf et al.
79
This pilot study was conducted within the nursing sciences subproject ‘‘Monitoring the impact of the DRG-payment system on nursing service context factors in Swiss acute care hospitals.’’28 The nursing sciences subproject is part of the research program ‘‘Impact of Diagnosis-Related Groups (DRGs) on patient care and professional practice’’ (IDoC), a large-scale multiprofessional mixed-methods evaluation study in Switzerland, investigating the impact of the introduction of SwissDRGs.29,30 In this article, we describe the development of the new instrument and present the results of our pilot study.
Methods Design The study was designed as a cross-sectional pilot survey to develop and test the newly developed moral distress instrument.
Participants and setting The study was conducted on eight units drawn from internal medicine, surgery, and intensive care at a single university hospital in German-speaking Switzerland. The units were chosen based on whether they offered a representative mix of specialty fields and patient populations in relation to the overall population of interest. Within these units, 294 RNs were eligible for participation. In addition to having a Swiss nursing diploma or foreign equivalent, the participants had to be engaged in direct care of patients.
Data collection In April 2011, nurses were mailed an information letter describing the goal of the survey and data collection procedures. This first letter instructed the nurses that they could provide informed consent by filling in the questionnaire. In a second letter, nurses were asked to fill out the web-based questionnaire within a month, using the online link provided. In order to support nurses, the project manager paid scheduled visits to the participating units and reported the current response rate of the online questionnaire. Concurrent with the pilot study, the nurses documented (via email or using a feedback form posted in the unit) any difficulties associated with filling out the questionnaire. Additionally, over the course of the month-long data collection, the project manager recorded verbal feedback received during regularly scheduled visits to the participating units.
Instrument development After an extensive literature search, the Moral Distress Scale developed by Hamric and Blackhall for intensive care nurses was chosen as the basis for our German-context instrument for acute care. This was based on the wide-spread acceptance of their theoretical framework and the level of development of the scale. Hamric and Blackhall’s scale is a revised version of Corley’s original questionnaire and consists of 19 items, which are to be answered on a 5-point Likert scale. The internal consistency measured by Cronbach’s alpha was 0.83.4,9,15 Three independent clinical nurse specialists, familiar with the theoretically based concept of moral distress and possessing long-standing first-hand experience in the intended field of application, conducted an initial test of face validity of this revised version of the English scale. Based on that, we selected 9 items for general acute care. This type of reduction has been undertaken in other studies in the past. For example, a study on moral distress among acute care nurses was conducted in the United States, in which 79
80
Nursing Ethics 22(1)
7 items of Hamric and Blackhall’s scale were selected.31 Another example is a Japanese version developed for use in psychiatric nursing in which 8 of the original scale items were eventually retained.25 Corley recommended the use of context-specific adaptations and Hamric and Blackhall also regarded them as a necessity.4,8 The 9 items selected were then translated into German by two nurses, both native speakers of German and fluent in English. Their translation was tested for conceptual and semantic consistency by two other nurses who are native speakers of English and fluent in German. It became apparent that specific phraseology would have to be adapted to the context of acute care nursing in Switzerland. Specific components had to be tested for their relevance regarding in terms of the extended practical use of the adapted questionnaire.32,33 A group of 10 nursing experts, with many years’ experience as RNs in clinical practice in the relevant field and who were from acute care units that would later participate in the main study, received an overview of the concept of moral distress from one of the researchers. Afterward, the nursing experts assessed the 9 finalized items regarding their applicability, semantic consistency, and comprehensibility. No further adaption was necessary. In our Moral Distress Scale, each item describes a potential moral distress–inducing situation. Using a 5-point Likert scale (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’), nurses indicate how often in the preceding 12 months they have experienced each situation and the level of disturbance associated with the event (0 ¼ ‘‘none,’’ 4 ¼ ‘‘very high’’). Even if they have not experienced a given situation, they indicate how disturbing it would be if it were to occur in their practice. During data analysis, an average value with a standard deviation (SD) and range can be derived from the responses of multiple nurses to each component.4,8 For the purposes of data collection and in accordance with Corley’s approach, a definition of moral distress was provided with the questionnaire.4 This was to impart a better understanding of the phenomenon, given that it is currently not an established concept in the Swiss nursing environment. According to the definition, the experience of moral distress is linked to a nurse’s professional ethical principles. These principles may provide the foundation upon which decisions are made regarding which course of action is best and which procedures are in the patient’s best interest. If constraints inherent in the situation prevent the nurse from acting in accordance with his or her moral judgment, the nurse will experience moral distress.34 In light of this, it would be worthwhile to recognize the significance of professional ethical principles in the day-to-day practice environment. This would improve the ability to gauge the extent to which conditions and situations have the potential to trigger moral distress. In order to garner a response to this, an additional item was added to the questionnaire in which nurses were asked about the role of professional ethical principles in decisions about care. The professional ethical principles referenced here originate from the Swiss Association of Nurses.35,36 To support nurses’ understanding of the item, the definition referenced above was provided with the questionnaire. This item was also measured on a 5-point Likert scale (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’) for the frequency with which the nurse relied on professional ethical principles when making decisions regarding patient care. The resulting questionnaire comprised 10 items and was designed to be filled in by the study participants electronically. The administration of the survey was designed according to the procedures outlined in the guidelines for Good Clinical Practice. It was accessible by means of individual registration via any personal computer connected to the Internet.37 Corley’s original format for the Moral Distress Scale served as a template for the questionnaire. Due to technical restrictions, the qualities of ‘‘frequency’’ and ‘‘level of disturbance’’ had to be re-formatted in two rows, meaning that for each item, frequency had to be entered in the upper row while the estimated level of disturbance was entered in the lower row. The nurses were able to fill out the survey during working hours. The nurses documented any difficulties they had using or understanding the questionnaire and the associated online collection of personal data concurrently with completing the pilot questionnaire. 80
Kleinknecht-Dolf et al.
81
Data analysis A descriptive analysis of data was carried out. The analysis of the occurrence of missing data indicated instances where a questionnaire item may have been unclear or ambiguous. More advanced statistical analyses of the psychometric qualities of the questionnaire will take place once the first cross-sectional data collected under the nursing sub-study have been generated. In order to prove the face validity of the results, they were discussed with a sample of participants of the pilot study for verification regarding the situations they experienced. Based on the definition of moral distress as provided to them, the clinical nurse specialist responsible for a particular practice area gave a subjective overall assessment of moral distress (high/moderate/low) regarding the anticipated results. In addition, the distribution of calculated mean values relating to specific questionnaire responses was compared to previous studies. The analysis was conducted using SPSS for Windows, Version 19.
Ethical considerations The study proposal was approved by the cantonal ethics committee. All nurses invited to participate in the survey were first informed of the background and aim of the study by one of researchers. They were also advised that their participation was voluntary and that personal data would be used only in pseudonymized form. All participating nurses provided informed consent for the interviews online and were assured of data confidentiality. The participating nurses could opt out of the questionnaire at any time by clicking on the corresponding item ‘‘I do not want to continue filling out and/or do not want to complete the questionnaire.’’
Results Response rate The online questionnaire on moral distress was filled in by 160 RNs, resulting in a response rate of 55%. Among the various units, as few as 6 and as many as 38 nurses participated. The response rate ranged from 24% to 90%.
Work characteristics of the respondents Of the 160 RNs participating, 123 (76%) had been working in their unit for longer than 1 year at the time of the survey, and 142 (88%) were either employed full-time or working over 50% of full-time hours.
Missing data Of the 160 RNs, there were 11 participants who intentionally did not answer all of the questions regarding moral distress. This led to 46 missings occurring, giving an overall missing rate of 1.5%. Within the dimensions frequency or level of disturbance, no item carried a missing response number of greater than 8 (5%). The number of questions left unanswered was higher for questions pertaining to the level of disturbance (n ¼ 37, distributed over all 9 items) than for questions describing frequency (n ¼ 9, distributed over 6 items). In the nine instances where questions regarding frequency were not answered, questions regarding the level of disturbance were also left unanswered. Of the 149 participants who had agreed to fill out the questionnaire completely, there were three missings in the item responses. These missings were not replaced. 81
82
Nursing Ethics 22(1)
Range of answers The responses to the item in which participants were asked to assess the relevance of professional ethical principles ranged from 1 to 4 (0 ¼ ‘‘never,’’ 4 ¼ ‘‘very often’’). The responses to the items for the assessment of moral distress, including frequency and level of disturbance, ranged between 0 (‘‘never’’ or ‘‘none’’) and 4 (‘‘very often’’ or ‘‘very high’’). It is noteworthy that all participants indicated that they had, at least on one occasion (value ‘‘frequency’’ ¼ 1), experienced a moral distress–inducing situation and that they experienced this at minimum as a mild disturbance (value ‘‘level of disturbance’’ ¼ 1).
Proportions of answers The item questioning how often professional ethical principles play a role in everyday nursing decisions was answered with a mean of 3.36 (SD ¼ 0.69); no one answered that professional ethical principles never play a role in everyday nursing decisions. The four situations having the potential to trigger moral distress that were found to occur most often were ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (M ¼ 2.40, SD ¼ 0.96), ‘‘work with levels of nurse or other care provider staffing that I consider unsafe’’ (M ¼ 1.94, SD ¼ 1.29), ‘‘watch patient care suffer because of a lack of provider continuity’’ (M ¼ 1.93, SD ¼ 0.92), and ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (M ¼ 1.80, SD ¼ 1.07). Interestingly, the four situations perceived as being the most disturbing were the same, but in a different order: ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (M ¼ 2.34, SD ¼ 1.09), ‘‘work with levels of nurse or other care provider staffing that I consider unsafe’’ (M ¼ 2.33, SD ¼ 1.38), ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (M ¼ 2.30, SD ¼ 1.19), and ‘‘watch patient care suffer because of a lack of provider continuity’’ (M ¼ 2.13, SD ¼ 1.12). The results of the entire questionnaire are shown in detail in Table 1; the frequency and levels of disturbance of these 4 items are represented graphically in Figure 1.
Feedback from nurses regarding the comprehensibility, feasibility, and effort associated with the collection of data Most participants found the questionnaire comprehensible. Some criticized the phraseology of certain statements as overly convoluted or too complicated. Another criticism was directed at the double negatives contained in some statements. One unit leader found that the questionnaire was only practicable for leaders working mainly in day-to-day nursing practice and not as much for those involved in unit management. The feedback of nurses regarding the feasibility and the effort associated with the collection of data were ambivalent. The electronic format of the questionnaire generally received very positive comments as well as the fact that it could be completed by accessing any Internet browser. While going through the online registration process, designed according to the procedures outlined in the guidelines for Good Clinical Practice, participants criticized the process as being too complicated. In spite of their interest in taking part, this deterred some from participating and filling in the questionnaire. Given that the questionnaire takes about 5 min to complete, these potential participants found a registration process (prior to online access), that took nearly as long to complete as the questionnaire itself, to be too time consuming.
Feedback from nurses regarding the results Some of the nurses who had taken part in the pilot study attended a presentation and discussion of the results held at each department. They confirmed that the results reflect their subjective assessment of conditions in 82
83
Professional ethical principles 1. I rely on professional 159 ethical principles when making decisions regarding patient care. Moral distress 158 1. Provide less than optimal care due to pressures from administrators or insurers to reduce costs. 159 2. Witness healthcare providers giving ‘‘false hope’’ to a patient or family. 159 3. Carry out the physician’s orders for what I consider to be unnecessary tests and treatments. 157 4. Avoid taking action when I learn that a physician or nurse colleague has made a medical error and does not report it.
N
49 54 (30.8%) (34%)
27 56 54 (17.0%) (35.2%) (34.0%)
45 24 (28.7%) (15.3%)
24 (15.1%)
2 (1.3%)
79 (50.3%)
6 (3.8%)
22 (13.8%)
49 50 33 (31.0%) (31.6%) (20.9%)
3
17 (10.8%)
2
2 13 70 (1.3%) (8.2%) (44.0%)
1
0 (0.0%)
0 (¼ never)
3 (1.9%)
20 (12.6%)
10 (6.3%)
9 (5.6%)
74 (46.5%)
.69
–
n
.78
2.40
.97 154
.96 156
1.65 1.09 155
1.80 1.07 152
3.36
4 (¼ very often) Mean SD
Proportion of answers over scale, n (%)
Frequency
39 (25.3%)
9 (5.8%)
23 (14.8%)
14 (9.2%)
–
0 (¼ none) –
2
26 37 (16.9%) (24.0%)
26 46 (16.7%) (29.5%)
30 30 (19.4%) (19.4%)
25 39 (16.4%) (25.7%)
–
1
–
–
–
Mean SD
22 2.34 1.09 (14.1%)
(continued)
31 21 1.80 1.38 (20.1%) (13.6%)
53 (34%)
46 26 2.14 1.32 (29.7%) (16.8%)
50 24 2.30 1.19 (32.9%) (15.8%)
–
3
4 (¼ very high)
Proportion of answers over scale, n (%)
Level of disturbance
Table 1. Frequency and level of disturbance of the items on professional ethical principles and the items on moral distress.a
84 73 (45.9%) 22 (13.8%)
112 (70.0%) 8 (5.0%) 26 (16.3%)
160
160
160
160
0 (¼ never)
159
N
Frequency
2 0 (0.0%)
3
1 (0.6%)
38 36 39 (23.8%) (22.5%) (24.4%)
45 63 39 (28.1%) (39.4%) (24.4%)
33 11 (20.6%) (6.9%)
78 41 17 (48.8%) (25.6%) (10.6%)
71 14 (44.7%) (8.8%)
1
21 (13.1%)
5 (3.1%)
3 (1.9%)
2 (1.3%)
1 (0.6%)
.92 158
.81 158
.90 157
.70 155
n
1.94 1.29 158
1.93
.44
1.37
.65
4 (¼ very often) Mean SD
Proportion of answers over scale, n (%)
SD: standard deviation. a German items were translated for this publication.
5. Be required to care for patients I don’t feel qualified to care for. 6. Work with nurses or other healthcare providers who are not as competent as patient care requires. 7. Ignore situations of suspected patient abuse by caregivers. 8. Watch patient care suffer because of a lack of provider continuity. 9. Work with levels of nurse or other care provider staffing that I consider unsafe.
Table 1. (continued)
22 (13.9%)
14 (8.9%)
64 (40.5%)
19 (12.1%)
58 (37.4%)
0 (¼ none)
2
Mean SD
57 16 2.11 1.21 (36.3%) (10.2%)
28 19 1.48 1.45 (18.1%) (12.3%)
3
23 36 (14.6%) (22.8%)
32 47 (20.3%) (29.7%)
2.13 1.12
35 42 2.33 1.38 (22.2%) (26.6%)
49 16 (31.0%) (10.1)
15 24 23 14.6%) 32 1.65 1.60 (9.5%) (15.2%) (20.3%)
33 32 (21.0%) (20.4%)
30 20 (19.4%) (12.9%)
1
4 (¼ very high)
Proportion of answers over scale, n (%)
Level of disturbance
Kleinknecht-Dolf et al.
85
Figure 1. Stacked bar plots of (a) the most frequent and (b) the most disturbing items of the Moral Distress Scale.
their practice environment and their experience of moral distress. For each item, the response was illustrated with specific examples consistent with the results from the practice environment. For example, it was confirmed that patients were regularly discharged or transferred too early due to insufficient reimbursement or because of the need to clear beds for new patients. Nurses reported having to carry out physician-ordered tests or treatments that seemed to them to be unjustified and therefore unnecessary. This situation was often preceded by a lack of interprofessional communication so that the nurses were unaware of the reasoning behind a particular medical approach. Additionally, treatment plans in certain instances were not followed consistently, for whatever reason, leading the nurses to question their validity. The lack of continuity reported to be rife among nursing and medical personnel was regarded as potentially detrimental to the quality of treatment and care. Continuity of treatment and care were assessed as insufficient or inadequate (depending on the situation) when the implementation of primary nursing encountered organizational boundaries. Substitutions, caused by staff training and the rotation schedule of physicians, also had an effect. The insufficient staff coverage assessed by more than one-third of the nurses as frequent or very frequent can be accounted for by several notices to quit, in combination with difficulties in recruitment at the time of data collection. None of the nurses taking part in the evaluation of the results criticized the response format as being inadequate or as presenting a barrier to submitting their assessment properly. The nurses accounted for the varying levels of disturbance experienced in different moral distress– inducing situations by explaining that the experience of distress is dependent not only on the frequency with which the incident occurs but also on the effect a particular incident has on the patient or on a particular nurse. The comparison of the results with the estimates regarding moral distress in the units given by the clinical nurse specialists responsible for those units shows that on six of the eight units in question, their estimates corresponded in general with the overall results. Regarding the other two units, the clinical nurse specialist responsible for one unit estimated the collective stress level of the entire responses as too low, and in the case of the other unit, the estimate of the clinical nurse specialist was too high. 85
86
Nursing Ethics 22(1)
Discussion The aim of this pilot study was to examine the comprehensibility, the manageability, and the effort associated with a questionnaire on moral distress newly developed for the German-speaking context. The response rate of 55% for the study, which was designed as a web-based (online) survey, is in accordance with the response rate usual for such surveys.38 However, although each unit voluntarily registered to participate and had the same information regarding the survey, participation nevertheless varied considerably. That this was due to internal conditions on the units was subsequently confirmed in the evaluation discussions. On the unit with the highest response rate, the nurse manager and the clinical nurse specialists issued daily reminders of the survey during the change-of-shift report throughout the data collection period. This was to remind the nurses of the study in the midst of the hectic of the work day so that it would not be forgotten. In the process, no pressure was exerted on the nurses, and there was no tracking of who filled out the survey. The unit with the lowest response rate was experiencing a period of upheaval with high staff turnover. This may highlight the importance of appropriate on-site support for online surveys. Due to the relatively low response rate of certain units, no unit-specific sub-analyses could be carried out. Unfortunately, the lack of an equivalent control group means that the extent to which the online survey influenced the response behavior of the nurses cannot be determined. The literature is not in agreement in this regard, with certain studies showing no disparities in the response behaviors,39 while other authors found corresponding differences.40 However, what is known is that the format of the questionnaire also influences response behavior in online surveys. In the case of this pilot study, the questionnaire had to be re-formatted; the two parallel columns for entering answers regarding frequency and disturbance had to be converted to two horizontal parallel rows. These changes may have affected the response behavior and, as a result, the reliability and validity of the questionnaire as well.41,42 The relatively low number of missings is encouraging, with three missings from the total of 149 nurses who had agreed to complete the questionnaire in full. Based on the high proportion of fully completed questionnaires, it may well be concluded that these particular participants overlooked the items in question and that the failure to complete the survey in full was not due to an ambiguous formulation of the item. This interpretation is supported by fact that in each instance, one of the two dimensions (either frequency or disturbance) was answered. Unfortunately, it is not known why 11 participants did not wish to complete the questionnaire in full. It is possible that they found the formulation of the items to be too complicated, or that the questions regarding disturbance were more difficult to answer than those pertaining to frequency. Or possibly the participants did not realize that they could also give a hypothetical answer in those instances where they indicated a frequency of 0. Given the feedback from the participating nurses, an attempt needs to be made during the further development of the scale to come up with a simpler and more practice-focused formulation of the items. It is unfortunate that an unknown number of the nurses invited to participate declined to fill out the questionnaire due to the effort associated with the application procedure. For this reason, we need to simplify the application procedure while continuing to comply with the Guidelines for Good Clinical Practice.37 The results highlight the significant role of professional ethical principles in nurses’ day-to-day practice environment. Their prominence illustrates the importance of taking professional ethical principles into account in discussions regarding the role of nursing in the interprofessional treatment process as well as in efforts to avoid or reduce moral distress.43,44 The results also demonstrate that each of the statements regarding potentially moral distress–inducing situations set out in the questionnaire had relevance for the nurses in the practice environment, albeit with variations in frequency and in the intensity of disturbance experienced. The specific narratives (regarding patient or unit-related situations) related by the participating nurses during the evaluation discussions also demonstrated that the nurses had correctly understood the intended meaning of the statements. Moreover, 86
Kleinknecht-Dolf et al.
87
none of the participating nurses reported being unable to give the assessment due to a potential response not being offered. This indicates that the questionnaire’s answer scale appears to cover the required spectrum of occurrences encountered in the nurses’ practice environment and that the answer scale is distributed (albeit skewed) over all answer categories. In some of the earlier studies involving nurses in similar settings, a total score for the characteristics of frequency and disturbance was calculated by combining the scores of the individual items for these categories.45,46 In this study, this approach was not taken. The discussion of the results with the participants showed that frequency and disturbance (in the context of potential moral distress–inducing situations) were assessed in relation to the impact they have on patients and nurses. For this reason, the values of individual items are not comparable and consequently should not be added up to a total score. Moreover, this study shows that a more frequent occurrence of certain situations does not necessarily correlate with a correspondingly higher perceived level of disturbance. This is shown in the results themselves. For example, in that the frequency of occurrence for Item 3 (‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’), with a median value of 2.4, received a higher estimation than the frequency of occurrence for Item 1 (‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’) which had a median value of 1.80. Nonetheless, the level of disturbance experienced associated with both situations appears to be roughly comparable (Item 1: M ¼ 2.30 and Item 3: M ¼ 2.34). In subsequent discussions of the results with the nurses, they reported that in some situations, a certain adaptation or even resignation takes place and that the perception of disturbance is not heightened. For example, in the situation where nurses carry out physician-ordered tests or treatments, they deem to be unnecessary (Item 3). This indicates that an increase in the occurrence of moral distress–inducing situations does not necessarily have to lead to a heightened sense of disturbance. For this reason, the decision was taken not to form one product out of the values for frequency and those for level of disturbance as was done, to a certain extent, in other studies on moral distress.8 The frequency and level of disturbance associated with potentially moral distress–inducing situations need to be examined in a more differentiated manner. A comparison of the results of this study with those from earlier studies shows that the two items ‘‘carry out the physician’s orders for what I consider to be unnecessary tests and treatments’’ (Item 3) and ‘‘work with levels of nurse provider staffing that I consider unsafe’’ (Item 9) are also among those items with the highest values.1,2,4,47 Comparisons with the aforementioned studies are limited by the fact that not only different versions of the Moral Distress Scale developed by Corley15 in 1995 were used but also that these differed in the number of items and in the characteristics of the answer scale. Rather, they are also limited regarding diverse modes of calculation. In this respect, the extent to which such comparisons can be carried out is limited. It must also be taken into account that moral distress and the situations that may induce it are situationally and culturally specific phenomena.8,23,26 This may also explain why the items ‘‘provide less than optimal care due to pressures from administrators or insurers to reduce costs’’ (Item 1) and ‘‘watch patient care suffer because of a lack of provider continuity’’ (Item 8), which in this study were rated relatively highly as regards frequency and disturbance, were rated lower in the studies mentioned above. Within the context of this pilot study, the selected items, generated from Corley’s Moral Distress Scale as well as expert opinions and discussions, were shown to be clinically relevant. In addition, they illustrate the frequency and degree of the associated disturbance experienced by the nurses who are affected. This can be understood to be an indication of the face validity of the present questionnaire as well as an initial indication of its construct validity. However, there was no examination of whether, in addition to the statements given, there were other situations relevant to the experience of moral distress. It is conceivable that there are situations in Swiss hospitals that would not have relevance in other settings and, as a result, were not recorded in our Moral Distress Scale. In light of the potentially substantial consequences of moral distress for healthcare professionals that have been shown in international studies, we introduced moral distress as a new concept in our preliminary 87
88
Nursing Ethics 22(1)
monitoring model of the mentioned study ‘‘Monitoring the impact of the DRG-payment system on nursing service context factors in Swiss acute care hospitals.’’28 Currently, there is also a lack of evidence regarding the relationship between moral distress and quality of care, indicating a need for further research in the field of nursing.12,48 We hope, with the results of our monitoring model, we will also contribute new knowledge to this question.
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 DRGs. Given the significance of professional ethical principles in day-to-day nursing practice, these results could serve as early indicators in intraprofessional as well as interprofessional discussions on collaboration between nurses and physicians regarding the prevention or reduction of moral distress. On the basis of these initial results, there needs to be a deeper examination of the concept of moral distress in the context of Swiss–German acute care hospitals and the questionnaire must be refined accordingly. The clarity of formulation and the discrimination between the items must be improved in order to facilitate the interpretation of results. Now that the relevance of all of the statements collected is known, the psychometric properties of the present questionnaire will have to be examined more deeply as well as its completeness regarding potential distress-inducing situations. The majority of the target user group seemed to find the questionnaire manageable and comprehensible. In order to improve the acceptance of the questionnaire, improvements to the wording will have to be made, and the administrative effort associated with filling it out online will have to be optimized. Acknowledgments Ethics committee and reference number: Kantonale Ethikkommission Zu¨rich, Stampfenbachstrasse 121, CH 8090 Zu¨rich; reference number: KEK-ZH-NR: 2011-0091. Conflict of interest The authors report no conflicts of interest. Funding The study was funded by the Swiss National Science Foundation, Ka¨the-Zingg-Schwichtenberg Foundation, Gottfried and Julia Bangerter-Rhyner Foundation, and the Olga Mayenfisch Foundation. References 1. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics 2007; 14(3): 344–359 (PMID: 17459818). 2. Elpern EH, Covert B and Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005; 14(6): 523–530. 3. Rice EM, Rady MY, Hamric AB, et al. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. J Nurs Manag 2008; 16(3): 360–373 (PMID: 18324996). 4. Corley MC, Elswick RK, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001; 33(2): 250–256 (PMID: 11168709). 5. Hamric AB, Davis WS and Childress MD. Moral distress in health care professionals. Pharos Alpha Omega Alpha Honor Med Soc 2006; 69(1): 16–23. 6. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum 1987–1988; 23(1): 16–29. 88
Kleinknecht-Dolf et al.
89
7. Gutierrez KM. Critical care nurses’ perceptions of and responses to moral distress. Dimens Crit Care Nurs 2005; 24(5): 229–241. 8. Hamric AB, Borchers CT and Epstein EG. Development and testing of an instrument to measure moral distress in health care professionals. AJOB Prim Res 2012; 3(2): 1–9. 9. Hamric AB and Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 2007; 35(2): 422–429. 10. Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984. 11. Lu¨tze´n K and Kvist BE. Moral distress: a comparative analysis of theoretical understandings and inter-related concepts. HEC Forum 2012; 24(1): 13–25. 12. Hamric AB. Empirical research on moral distress: issues, challenges, and opportunities. HEC Forum 2012; 24(1): 39–49. 13. Ka¨lvemark S, Hoglund AT, Hansson MG, et al. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med 2004; 58(6): 1075–1084 (PMID: 14723903). 14. Sile´n M, Svantesson M, Kjellstro¨m S, et al. Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability. J Clin Nurs 2011; 20: 3483–3493. 15. Corley MC. Moral distress of critical care nurses. Am J Crit Care 1995; 4(4): 280–285. 16. Papathanassoglou EDE, Karanikola MNK, Kalafati M, et al. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care 2012; 21(2): e41–e52. 17. Lauxen O. Moralische Probleme in der ambulanten Pflege—eine deskriptive pflegeethische Untersuchung. [Moral problems in home health care–a descriptive ethical study]. Pflege 2009; 22(6): 421–430. 18. Tewes R. Moralische Intelligenz: wertorientierte Fu¨hrung zahlt sich aus [Moral Intelligence: value-based management pays for itself]. In: Tewes R (ed.) Fu¨hrungskompetenz ist lernbar [Leadership can be learned]. 2. Auflage ed. Berlin, Heidelberg: Springer, 2011, pp. 47–60. 19. Zimmermann P, Jacobs H and Kowalski JT. ISAF und die Seele—zwischen Scha¨digung und Wachstum [ISAF and the soul - between damage and growth]. In: Seiffert A, Langer PC and Pietsch C (eds) Der Einsatz der Bundeswehr in Afghanistan [Deployment of the German military in Afghanistan]. Berlin, Heidelberg: Springer, 2012, pp. 143–152. ¨ bertherapie am Lebensende? Gru¨nde fu¨r ausbleibende 20. Albisser Schleger H, Pargger H and Reiter-Theil S. ‘‘Futility’’—U 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 fu¨r Palliativmedizin 2008; 9: 67–75. 21. Nienhaus A, Westermann C and Kuhnert S. Burn-out bei Bescha¨ftigten in der stationa¨ren Altenpflege und in der Geriatrie [Burnout among elderly care staff. A review of its prevalence]. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 2012; 55(2): 211–222. 22. Lu¨tze´n K, Cronqvist A, Magnusson A, et al. Moral stress: synthesis of a concept. Nurs Ethics 2003; 10(3): 312–322. 23. Mashiach Eizenberg M, Desivilya HS and Hirschfeld MJ. Moral distress questionnaire for clinical nurses: instrument development. J Adv Nurs 2009; 65(4): 885–892. 24. Lazzarin M, Biondi A and Di Mauro S. Moral distress in nurses in oncology and haematology units. Nurs Ethics 2012; 19(2): 183–195. 25. Ohnishi K, Ohgushi Y, Nakano M, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics 2010; 17(6): 726–740. 26. Harrowing JN and Mill J. Moral distress among Ugandan nurses providing HIV care: a critical ethnography. Int J Nurs Stud 2010; 47: 723–731. 27. Piers RD, Van den Eynde M, Steeman E, et al. End-of-life care of the geriatric patient and nurses’ moral distress. J Am Med Dir Assoc 2012; 13: 80.e7–80.e13. 28. Spirig R, Spichiger E, Martin JS, et al. Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals. Ger Med Sci 2014; 12: Doc07. 29. SwissDRG AG. Fallpauschalen in Schweizer Spita¨lern, Basisinformationen fu¨r Gesundheitsfachleute [Case-based prospective payment systems in Swiss hospitals, basic information for health care professionals]. Bern: SwissDRG AG, 2010. 89
90
Nursing Ethics 22(1)
30. Biller-Andorno N and Wild V. Impact of Diagnosis Related Groups (DRGs) on patient care and professional practice (IDoC): Universita¨t Zu¨rich—Ethik-Zentrum—Institut fu¨r Biomedizinische Ethik, http://www.ethik.uzh.ch/ ibme/forschung/drg.html (2010, accessed 5 February 2013). 31. Lawrence LA. Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nurs Forum 2011; 46(4): 256–268. ¨ bersetzung32. Martin JS, Vincenzi C and Spirig R. Prinzipien und Methoden einer wissenschaftlich akkuraten U spraxis von Instrumenten fu¨r Forschung und direkte Pflege [Principles and methods of good practice for the translation process for instruments of nursing research and nursing practice]. Pflege 2007; 20(3): 157–163. 33. Jones PS, Lee JW, Phillips LR, et al. An adaptation of Brislin’s translation model for cross-cultural research. Nurs Res 2001; 50(5): 300–304 (PMID: 11570715). 34. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650 (PMID: 12450000). 35. Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner SBK. Ethik in der Pflegepraxis [Ethics in nursing practice]. Bern: Zentralsekretariat SBK, 2003. 36. Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner SBK. Ethische Standpunkte 2, Verantwortung und Pflegequalita¨t [Ethical viewpoints 2, accountability and quality of care]. Bern: Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachma¨nner, 2007. 37. Guideline for good clinical practice E6(R1), 1996, http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/ Guidelines/Efficacy/E6_R1/Step4/E6_R1__Guideline.pdf 38. Kongsved SM, Basnov M, Holm-Christensen K, et al. Response rate and completeness of questionnaires: a randomized study of internet versus paper-and-pencil versions. J Med Internet Res 2007; 9(3): e25. 39. Brock RL, Barry RA, Lawrence E, et al. Internet administration of paper-and-pencil questionnaires used in couple research: assessing Psychometric Equivalence. Assessment 2012; 19(2): 226–242. 40. Whitehead L. Methodological issues in internet-mediated research: a randomized comparison of internet versus mailed questionnaires. J Med Internet Res 2011; 13(4): e109. 41. Dillman DA and Christian LM. Survey mode as a source of instability in responses across surveys. Field Method 2005; 17(1): 30–52. 42. Van Schaik P and Ling J. Design parameters of rating scales for web sites. ACM Trans Comput Hum Interact 2007; 14(1): 1–35. 43. Cribb A. Integrity at work: managing routine moral stress in professional roles. Nurs Philos 2011; 12: 119–127. 44. Cronqvist A, Theorell T, Burns T, et al. Caring about—caring for: moral obligations and work responsibilities in intensive care nursing. Nurs Ethics 2004; 11(1): 63–76. 45. Meltzer LS and Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004; 13(3): 202–208. 46. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: development of a web-based survey. Acad Med 2010; 85(1): 111–117. 47. Pauly B, Varcoe C, Storch J, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573 (PMID: 19671643). 48. Schluter J, Winch S, Holzhauser K, et al. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304–321 (PMID: 18388166).
90
