Moral Distress
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Article_Moral_Distress.pdf
Notice to CNE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:
1. Identify common causes of moral distress in critical care nurses who are caring for dying patients.
2. Describe the concept of psychological empow- erment and the 4 cognitions it encompasses.
3. Discuss the study findings as related to the relationship between moral distress intensity and frequency, psychological empowerment, and participant demographics.
To read this article and take the CNE test online, visit www.ajcconline.org and click “CNE Articles in This Issue.” No CNE test fee for AACN members.
By Annette M. Browning, RN, PhD, CNS
Background Critical care nurses providing care for adults at
the end of life may encounter moral distress when they cannot
do what they believe is ethically correct. Psychological empow-
erment can decrease moral distress among critical care nurses.
Objectives To describe the relationships between moral dis-
tress, psychological empowerment, and demographics in criti-
cal care nurses caring for patients at the end of life.
Method A total of 277 critical care nurses were surveyed via
the Moral Distress Scale and the Psychological Empowerment
Instrument. Responses were scored on a Likert scale of 1 to 7.
Results Moral distress intensity was high (mean 5.34, SD 1.32)
and positively correlated with age (r = 0.179, P = .01). Moral
distress frequency was moderate (mean 2.51, SD 0.87) and
negatively correlated with nurses’ collaboration in end-of-life
patient care conferences (r = -0.191, P = .007). Psychological
empowerment scores (mean 5.31, SD 1.00) were high and
positively correlated with age (r = 0.139, P = .03), years of
experience (r = 0.165, P = .01), collaboration in end-of-life-care
conferences (r = 0.163, P = .01), and end-of-life-care education
(r = 0.221, P = .001) and were negatively correlated with moral
distress frequency (r = -0.194, P = .01). Multiple regression
analysis revealed that empowerment was a significant predic-
tor of moral distress frequency (β= .222, P < .01).
Conclusion The significant negative correlation between psy-
chological empowerment and frequency of moral distress in
these nurses indicated that nurses with higher perceived empow-
erment experience moral distress less often. This finding is of
particular interest as interventions to decrease moral distress
are sought. (American Journal of Critical Care. 2013;22:143-152)
MORAL DISTRESS AND
PSYCHOLOGICAL
EMPOWERMENT IN CRITICAL
CARE NURSES CARING FOR
ADULTS AT END OF LIFE
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© 2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2013437
Challenges in the Critical Care Workplace
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Background The advent of life-support technology during the
past half century has drastically changed the focus of caring for dying patients. Critical care units were developed in order to monitor critically ill patients appropriately, and critical care nurses were provided specialized education for the purpose of providing optimal care for critically ill patients. Although advanced technology has brought with it the prom- ise of more efficient treatment techniques, extending life inappropriately and futile prolonging of patients’ suffering have become commonplace for critical
care nurses caring for dying patients,6
thus causing moral distress in critical care nurses.
Jameton7 was the first to define moral distress in the nursing literature. Moral distress was defined as discom- fort or internal conflict related to ethi- cal dilemmas encountered in nursing practice when constraints prevented the nurse from following the course
of action believed to be right. Obstacles contributing to the inability to act upon what the nurse believes to be right have many origins. Beckstrand and Kirchhoff1 identified several obstacles that 864 criti- cal care nurses perceived while providing end-of-life care, including the perception that their opinions related to end-of-life care decisions were not being recognized and valued. The highest ranking obstacles
in this study were as follows: Families not under- standing the term “life-saving measures” and its implications, families requesting life-saving measures contrary to patients’ wishes, and patients’ treatments continuing although painful or uncomfortable.
In 2006, the American Association of Critical- Care Nurses (AACN) identified end-of-life care chal- lenges as a significant source of moral distress in critical care nurses. AACN has issued a position statement on moral distress, proclaiming it a serious problem in nursing.8
Psychological empowerment is a mechanism by which people gain mastery of their affairs.9 In the nursing literature, empowerment has been examined on the basis of 2 conceptualizations, structural and psychological. Psychological empowerment (one’s belief in one’s ability to be empowered) was meas- ured in this study.
As critical care nurses develop a more active voice in collaboration with physicians, ethics com- mittees, and members of the multidisciplinary health care team, the facilitation of empowerment among nurses might decrease moral distress and enhance patient care outcomes at the end of life. No studies have been reported to date that specifically examine the relationship between moral distress and empow- erment in nursing thus, in this study, we sought to determine if such a relationship exists.
Moral Distress Related to End-of-Life Care
Several studies have associated levels of moral distress in nurses with the delivery of end-of-life care to patients.10-12 In most of the studies reviewed, the most common phenomenon related to end-of-life care that is causing moral distress in critical care nurses is the delivery of futile care. The delivery of futile care at the end-of-life was first examined by Wilkinson,13 who
One-fifth of the patients cared for by critical care nurses die in the intensive care unit.1 The American Association of Colleges of Nursing2 has expressed growing concern about an increase in the use of inappropriate life-support treatments related to end-of-life care. In the past decade, awareness of potential inadequacies in caring for the dying has been increasing, and
many of these inadequacies are related to the use of life support in critical care settings.3 In cases of futility, aggressive medical treatment at the end of life is well documented as a cause of moral distress in critical care nurses.4 Moral distress occurs when nurses are unable to per- form according to what they believe to be ethically correct. Increasing psychological empow- erment in nurses is a means of strengthening the impact that nurses have to innovatively influence decision making related to patient care.5 Increasing psychological empowerment may be a means of ameliorating moral distress in critical care nurses caring for dying adults.
About the Author Annette M. Browning is an associate professor of nursing and director of simulation learning at Biola University, La Mirada, California.
Corresponding author: Annette M. Browning, RN, PhD, CNS,
982 Big Sky Lane, Orange, CA 92869 (e-mail: annette. [email protected]).
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Moral distress occurs when
nurses are unable to do what they
believe to be ethically correct.
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4 consecutive weeks. If subscribers were interested in participating, they used a link that led them to the online survey, which started with a cover letter explaining the details of the study further.
Data Collection (Instruments and Procedure)
Two valid and reliable survey instruments were used in this study, the 32-item Moral Distress Scale (MDS)10 and the 16-item Psychological Empower- ment Instrument (PEI)22 in addition to the demo- graphic data survey (see Figure). The MDS-32 has been tested for content validity twice.23 All items were considered relevant in both testings. Test-retest relia- bility of the MDS-32 was 0.86 (P= .01).23 The high reliability may reflect redundancy of some items. The Cronbach alpha was 0.93 (P< .01), demonstrating high reliability. The MDS was later expanded to 38 items. These additional items were unrelated to end- of-life care, so the original 32-item MDS was used.
The MDS measures moral distress intensity, the level at which the nurse experiences painful feelings related to a given situation (none to great extent), and moral distress frequency, how often the nurse experi- ences the painful feeling associated with the distress- ful situation (never to very frequently) on a Likert scale from 1 to 7. The MDS uses 3 factors or subscales to measure moral distress: (1) individual responsibil- ity (refers to the nurse participating in care not agreed with or ignoring actions one should take—20 items), (2) not in patient’s best interest (refers to participating
built on the work of Jameton.7 Multiple studies4,10,13-18
have shown that futile care, where nurses perceived that the patient would not benefit from care, caused the most significant levels of moral distress in nurses.
Theories of Psychological Empowerment
Bandura19 theorized that degrees of empower- ment are perceived as one’s sense of self-efficacy is facilitated. Self-efficacy occurs when one’s sense of self-determination is strengthened or one’s sense of powerlessness is weakened. Furthermore, the strength of one’s perceived empowerment determines how obstacles are viewed and the degree to which one overcomes the obstacles.20
Conger and Kanungo21 took self-efficacy a step further by reiterating that true empowerment occurs when convictions of one’s own effectiveness are suc- cessfully executed and not merely hoped for. Thomas and Velthouse9 further postulated empowerment as multifaceted, encompassing 4 cognitions: (1) meaning, the value one attaches to one’s standards, (2) competence, the belief that one is able to carry out one’s beliefs in action, (3) self-determination, the sense that one has control over one’s autonomy, and (4) impact, the degree to which one perceives one’s work as having influence.
Conceptual Framework Although critical care nurses may perceive them-
selves as having some degree of empowerment with respect to decision making related to end-of-life care, they see themselves as often unable to contribute significantly to decisions they believe to be correct. This “gap” between nurses having empirical knowl- edge and not being able to apply that knowledge effectively was the impetus for this study intended to explore the association between moral distress intensity, moral distress frequency, psychological empowerment, and select demographics of critical care nurses (see Figure).
Methods Sample
A cross-sectional descriptive survey design was used to study a target population of critical care nurses caring for adults at the end of life. A sample of 277 critical care nurses who were on AACN’s e-mail newsletter list were recruited for this study. Inclusion criteria were as follows: (1) must be a critical care staff nurse and (2) must have had experience with caring for dying adults in the critical care setting before completing the survey tools. A brief paragraph describ- ing the study was placed in the AACN newsletter for
Figure Conceptual framework for the relationship between moral distress (intensity and frequency), psychological empowerment, and select demographics.
Abbreviations: AACN, American Association of Critical-Care Nurses; ELNEC, End-of- Life Nursing Education Consortium.
Psychological empowerment
• Meaning
• Competence
• Self-determination
• Impact
Moral distress Intensity
Frequency
• Not in patient’s best interest
• Individual responsibility
• Deception
Nursing characteristics
• Age
• Number of years in critical care
• Level of education
• Work status
• AACN membership
• AACN specialty certification
• Active collaboration in end-of- life patient care conferences
• ELNEC critical care training
• End-of-life care continuing education (within past year)
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in care that the nurse considers inappropriate because of futility for the patient— 7 items), and (3) decep- tion (refers to the nurse not addressing issues hon- estly, related to impending death of a patient—3 items). Data from 2 items (12 and 13) on the MDS-32 pertain to children. These 2 items were omitted from the tables presented here because of the study’s focus on the care of adults; however, all 32 items were administered in the survey given to participants.
The PEI is highly reliable and valid,22,24 with reported reliability coefficients ranging from 0.62 to 0.74. The PEI used 4 domains or subscales, previously defined, to measure psychological empowerment: (1) meaning, (2) competence, (3) self-determination, and (4) impact. Each domain addressed 4 items (see Figure) measuring empowerment. Items were scored as follows: 7 = very strongly agree, 6 = strongly
agree, 5 = agree, 4 = neutral, 3 = dis- agree, 2 = strongly disagree, 1 = very strongly disagree.
Quantitative data were collected from October 28, 2010 to November 25, 2010. From the approximately 80 000 e-mailed newsletters, 277 recipients returned the survey. The return rate was approximately 0.35%.
Participants were excluded from analyses when they left 25% or more responses blank on any given measure. For example, if a participant left 4 out of 10 responses blank on the MDS, they were left out of analyses comparing moral distress scores with other scale scores. They were included, however, in the descriptive statistics for other measures that were sufficiently completed (<25% missing).
Approval by the institutional review board of the University of San Diego for the protection of human subjects was obtained for this study. The institutional review board determined that written informed consent was not required. A cover letter approved by the institutional review board was posted on the AACN Web site, informing readers about the follow- ing information: that participation in the study was voluntary and study data were kept confidential, risks and benefits of participation, and how to contact the investigator for questions. The participants were assured of their anonymity both in data collection and the publication of data. All data were stored on a pass- word-protected computer. No identifying information, including e-mail addresses, was included in the Excel spreadsheet uploaded from SurveyMonkey.
Statistical Analysis and Variables
Percentages were used to describe the categorical variables. Appropriate correlational statistics, based
on variable level of data (continuous or categorical), were used to examine relationships among variables. Moral distress intensity and moral distress frequency were 2 separate dependent or outcome variables measured by the MDS. Multiple linear regression analysis was used to examine associations between the dependent variable of moral distress intensity and the independent or predictor variables (psycho- logical empowerment and demographics) and the dependent variable of moral distress frequency and the independent or predictor variables (psychologi- cal empowerment and demographics).
Results The following demographics were found within
the sample: The participants had a mean age of 46.9 years (SD 10.4). The mean number of years of experi- ence working as a critical care nurse was reported as 17.45 (SD 11). Most participants (n = 234, 84.5%) were working full-time in critical care. The percentage of participants employed part-time was 11.6% (n=32). Only 1 participant was working per diem. More than half of the nurses (54.6%) reported being active par- ticipants in end-of-life patient care conferences. Most of the responding nurses had a bachelor of science degree in nursing (47.1%); 29.2% of the participants had an associate degree in nursing; 19.7% of the nurses had a master of science degree in nursing, and 3.3% of the participating nurses were doctorally prepared. Most of the participants (55.2%) had specialty certi- fication by the AACN, and most participants (54.6%) also reported having had end-of-life care education within the past year. A large majority of participating nurses (86%) reported being members of the AACN. Only 5.8% of the participants (n=16) reported partic- ipation in the critical care training provided by the End-of-Life Nursing Education Consortium (ELNEC).
Moral Distress Intensity and Moral Distress
Frequency
Moral distress intensity and moral distress fre- quency scores ranging from 0 to 2.33 were considered low, 2.34 to 4.66 moderate, and 4.67 to 7.00 high. Scores for moral distress scale subscales and total scores were calculated separately for both intensity and frequency (Table 1).
Mean scores for items on the moral distress intensity scale ranged from 4.39 to 6.05, with a overall mean total score of 5.34 (SD 1.32). The 3 highest-scoring items for moral distress intensity were “assisting [physician] who in my opinion is providing incompetent care” (mean 6.05), “work in a situation when the number of staff is too low and care is inadequate” (mean, 5.97), and “continue
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Most participants reported having had
end-of-life care education within
the past year.
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Table 1 Moral distress intensity and frequency of respondents (N=277) according to subscales: not in patient’s best interest, individual responsibility, and deception
Not in patient’s best interest
Individual responsibility
Deception
1. Follow family’s wishes for patient care I don’t agree with
2. Follow family’s wishes to continue life support when not in patient’s best interest
3. Follow physician’s orders for unnecessary tests
5. Initiate life-saving actions when I think it prolongs death
15. Carry out physician’s orders for unnecessary tests and treatments on terminally ill patients
22. Prepare a terminally ill elderly patient receiving mechanical ventilation for surgery to have a mass removed
23. Prepare an elderly severely demented patient who is a no code for placement of a gastrostomy tube
Not in patient’s best interest subscale score
4. Assist physician who performs test or treatment without patient’s consent
6. Ignore situations of suspected abuse of patient by caregivers
7. Ignore situations of inadequate consent from patient
8. Perform procedure when the patient is not adequately informed
9. Carry out work assignment in which I do not feel professionally competent
10. Avoid taking action when a nurse colleague has made a medication error
11. Let medical students perform painful procedures on patients solely to increase their skill
14. Assist physicians practicing procedures on a patient after cardiopulmonary resuscitation has been unsuccessful
16. Work with “unsafe” levels of nurse staffing
17. Carry out order to discontinue treatment because patient can no longer pay
18. Continue to care for a hopelessly injured patient receiving mechanical ventilation when no one will discontinue the ventilation
19. Observe without intervening when personnel do not respect patient’s dignity
20. Follow physician’s order not to tell patient the truth when he/she asks for it
21. Assist physician who in my opinion is providing incompetent care
24. Discharge patient based on diagnosis-related groups although he has many teaching needs
25. Provide better care for those who can afford to pay
26. Follow the family’s request not to discuss dying with a dying patient who asks about dying
27. Follow physician’s request not to discuss death with a dying patient who asks about dying
28. Work in a situation when the number of staff is too low and care is inadequate
32. Follow physician’s request not to discuss code status with family when patient is incompetent
Individual responsibility subscale score
29. Give medications intravenously during a code with no compressions or intubation
30. Give only hemodynamic stabilizing medications intravenously during a code with no compression or intubation
31. Follow physician’s request not to discuss code status with patient
Deception subscale score
Total of all subscales
4.81 (1.52)
5.47 (1.46)
5.22 (1.53)
5.72 (1.46)
4.39 (2.18)
5.09 (1.91)
5.24 (1.87)
5.13 (1.25)
5.27 (2.08)
5.51 (2.16)
5.42 (1.76)
5.36 (1.71)
5.27 (1.95)
4.89 (1.84)
5.40 (2.09)
5.09 (2.35)
5.82 (1.56)
5.36 (2.39)
5.88 (1.50)
5.67 (1.68)
5.83 (1.78)
6.05 (1.56)
5.15 (2.04)
5.20 (2.23)
5.79 (1.74)
5.76 (1.86)
5.97 (1.72)
5.50 (2.03)
5.50 (1.47)
4.68 (2.18)
4.49 (2.20)
5.54 (2.05)
4.92 (1.82)
5.34 (1.32)
4.08 (1.66)
4.45 (1.65)
4.28 (1.80)
3.73 (1.71)
3.71 (1.77)
2.42 (1.41)
3.17 (1.67)
3.69 (1.22)
2.01 (1.44)
1.60 (1.17)
2.22 (1.52)
2.21 (1.46)
1.91 (1.12)
2.05 (1.20)
2.00 (1.52)
1.45 (1.15)
3.57 (1.88)
1.43 (1.26)
3.61 (1.81)
2.21 (1.68)
1.86 (1.24)
2.49 (1.36)
1.95 (1.43)
1.67 (1.40)
2.22 (1.27)
1.98 (1.33)
2.91 (1.79)
1.91 (1.43)
2.15 (0.88)
2.29 (1.506)
2.30 (1.46)
1.87 (1.37)
2.16 (1.20)
2.51 (0.87)
Subscale Item Intensity Frequency
Mean (SD)
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to care for a hopelessly injured patient on a ventila- tor when no one will discontinue the ventilator” (mean 5.88). The lowest-scoring item for moral dis- tress intensity was “carry out [physician]’s orders for unnecessary tests and treatments on terminally ill patients” (mean 4.39).
Mean scores for items on the moral distress fre- quency scale ranged from 1.43 to 4.45, with an overall mean total of 2.51 (SD 0.87). The 3 highest-scoring items for moral distress frequency were “follow family’s wishes to continue life support when not in patient’s best interest” (mean 4.45), “follow [physician]’s orders for unnecessary tests” (mean 4.28), and “follow family
wishes for patient care I don’t agree with” (mean 4.08). The lowest-scoring item for moral distress frequency was, “carry out order to discontinue treat- ment because patient can no longer pay” (mean 1.43).
Total scores for both moral dis- tress intensity and moral distress fre- quency were determined for each of
the 3 subscale categories (Table 1). All moral distress intensity subscale totals were high: (1) not in patient’s best interest (mean 5.13, SD 1.25), (2) individual responsibility (mean 5.50, SD 1.47), and (3) decep- tion (mean 4.92, SD 1.82).
Moral distress frequency subscales were as follows: (1) not in patient’s best interest (mean 3.69, SD 1.22), (2) individual responsibility (mean 2.15, SD 0.88), and (3) deception (mean 2.16, SD 1.43). The total score for moral distress intensity was high (mean 5.34, SD 1.32), and the total score for moral distress frequency was moderate (mean 2.51, SD 0.87).
Psychological Empowerment
The PEI was used to determine levels of empow- erment of critical care nurses in the workplace. Data from this instrument were scored in the following manner: individual item mean scores, mean subscale scores, and a mean total score. Similar to moral dis- tress, PEI scores from 0 to 2.33 were considered low, 2.34 to 4.66 moderate, and 4.67 to 7.00 high.
PEI items ranged from moderate (mean 3.88) to high (mean 6.22). The highest scoring PEI item was, “I really care about what I do on my job” (mean 6.22, SD 1.16). The lowest scoring item was, “I have a great deal of control over what happens in my department” (mean 3.88, SD 1.52). PEI subscale scores were all high: meaning (mean 6.06, SD 1.09), competence (mean 5.92, SD 1.02), self-determination (mean 5.03, SD 1.18), and impact (mean 4.22, SD 1.47). Overall, the total PEI mean score indicated a high degree of psychological empowerment (mean 5.31, SD 1.00).
Correlational Analysis of Moral Distress and
Demographics
Weak but significant positive correlations were found between the moral distress item “not in patient’s best interest” and age (r= 0.179, P= .01) and ELNEC critical care training (r= 0.185, P= .008). Likewise weak but significant positive correlations were found between ELNEC training and the items “not in patient’s best interest” (r= 0.194, P= .006) and total score for moral distress frequency (r=0.165, P= .02). A weak but significant negative correlation was found between active collaboration in end-of- life patient care conferences and items related to deception (r= -0.191, P= .007).
Correlational Analysis of Empowerment and
Demographics
Several significant positive correlations were found between psychological empowerment and the nurses’ demographics (Table 2). Significant and moderate correlations were found between empow- erment related to competence and years of critical care experience (r= 0.255, P= .001). Other moderate and significant correlations were found between empowerment related to self-determination and col- laboration in end-of-life care conferences (r= 0.217, P= .001) and end-of-life care education in the past year (r= .209, P= .001). In addition, a significantly positive moderate correlation was found between empowerment related to impact and collaboration in end-of-life care conferences (r= 0.253, P= .001).
All empowerment subscale scores (meaning, competence, self-determination, and impact) and total empowerment scores significantly correlated positively with end-of-life care education in the past year (r= 0.221, P= .001). No correlations were found between empowerment and AACN membership or CCRN certification; therefore, these data were omit- ted from Table 2.
Moral Distress Intensity/Frequency and
Psychological Empowerment
Relationships between psychological empower- ment and moral distress intensity and frequency were computed by using a Pearson product coefficient. A moderate and significant negative correlation was found between moral distress frequency related to individual responsibility and empowerment related to impact (r= -0.249, P= .001) and moral distress fre- quency total scores and empowerment related to impact (r= -0.229, P= .002). Total psychological empowerment scores negatively correlated with moral distress frequency (individual responsibility subscale; r= -0.213, P= .004; see Table 2).
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Nurses with higher levels of perceived empowerment will experience moral
distress less often.
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predictor of moral distress frequency (β=.222, P<.01). For every 1-point increase on the PEI, moral distress frequency scores decreased by 0.222 points (P≤ .01). The analysis indicated that it can be predicted that ELNEC critical care trained nurses will experience moral distress more often, and nurses with higher levels of perceived empowerment will experience moral distress less often.
Discussion Moral distress intensity was high among critical
care nurses, whereas moral distress frequency was moderate to low. These findings are consistent with the results of Corley et al,23 in that the frequency was
Relationships between Moral Distress,
Empowerment, and Demographics
Multiple regression analysis was used to test if any demographic variables combined with total PEI scores were predictors of the frequency of experienc- ing moral distress. The results of the regression analy- sis indicated that 2 predictors explained 8.40% of the variance (R2 = 0.289, F2,171 = 7.801, P< .01). It was found that nurses’ having had ELNEC critical care training was a significant predictor of moral distress frequency (β=-.215, P< .01). Nurses who had received ELNEC critical care training had, on average, 21.5% higher scores for moral distress frequency. In addition, total psychological empowerment was a significant
Table 2 Correlational findings using Pearson’s r coefficient
r = 0.083 n = 258
r = 0.077 n = 257
r = -0.064 n = 253
r = 0.016 n = 256
r = -0.021 n = 258
r = 0.051 n = 256
r = 0.150a
n = 256
r = 0.032 n = 202
r = 0.119 n = 177
r = 0.144a
n = 203
r = 0.115 n = 170
r = -0.056 n = 202
r = -0.056 n = 193
r = -0.041 n = 202
r = -0.064 n = 186
r = 0.194a
n = 255
r = 0.255a
n = 254
r = 0.005 n = 250
r = 0.022 n = 253
r = -0.037 n = 255
r = 0.093 n = 253
r = 0.177a
n = 253
r = 0.042 n = 199
r = 0.079 n = 174
r = 0.059 n = 200
r = 0.062 n = 167
r = 0.001 n = 199
r = -0.159 n = 190
r = -0.115 n = 199
r = -0.136 n = 183
r = 0.090 n = 257
r = 0.110 n = 256
r = 0.036 n = 252
r = 0.217a
n = 255
r = 0.116 n = 257
r = 0.133a
n = 255
r = 0.209a
n = 256
r = 0.015 n = 201
r = 0.056 n = 175
r = 0.168a
n = 202
r = 0.062 n = 167
r = -0.103 n = 201
r = -0.177a
n = 192
r = -0.121 n = 201
r = -0.161a
n = 185
r = 0.076 n = 253
r = 0.096 n = 252
r = 0.151a
n = 249
r = 0.253a
n = 251
r = 0.149a
n = 253
r = 0.128a
n = 251
r = 0.196a
n = 251
r = 0.064 n = 196
r = 0.032 n = 171
r = 0.164a
n = 197
r = 0.057 n = 168
r = -0.161a
n = 196
r = -0.249a
n = 190
r = -0.065 n = 196
r = -0.229a
n = 183
r = 0.139a
n = 242
r = 0.165a
n = 241
r = 0.034 n = 238
r = 0.163a
n = 240
r = 0.099 n = 242
r = 0.125 n = 240
r = 0.221a
n = 241
r = 0.064 n = 189
r = 0.085 n = 166
r = 0.166a
n = 190
r = 0.095 n = 159
r = -0.111 n = 189
r = -0.213a
n = 183
r = -0.097 n = 189
r = -0.194a
n = 176
Abbreviation: ELNEC, End-of-Life Nursing Education Consortium. a Significance at α< .05.
ImpactSelf-determinationCompetence MeaningNurses’ demographics Total empowerment
Psychological empowerment
Age
Years of critical care experience
Work status
Collaboration in end-of-life care conferences
Education
ELNEC critical care training
End-of-life care education in the past year
Moral distress intensity
Not in patient’s best interest
Individual responsibility
Deception
Total moral distress intensity
Moral distress frequency
Not in patient’s best interest
Individual responsibility
Deception
Total moral distress frequency
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lower than the intensity, implying that the morally distressing events that the nurses experienced were not occurring often. Moral distress intensity was higher in our study than in the study by Corley et al. In our study, nurses reported the highest level of moral dis- tress intensity in the individual responsibility domain, with the second highest level of moral distress inten- sity related to the items not in patient’s best interest, although the difference in mean scores was negligible (0.37). In previous studies,10,13,15-18 researchers reported that the highest moral distress intensity resulted from items not in the patient’s best interest (futile care).
As nurses’ age increased, so did moral distress intensity. Nurses participating in end-of-life patient care conferences reported less moral distress frequency in being able to address issues related to the impend- ing death of a patient honestly. Overall, the more empowered nurses perceived themselves, the less often they experienced moral distress.
Nurses who reported having ELNEC critical care training experienced significantly greater levels of moral distress intensity and frequency in items related to “not in patient’s best interest” (participating in care that the nurse considered inappropriate because of futility for the patient). This may be explained by nurses, having gained more information regarding the correct actions to take in situations of delivering futile care to dying patients, felt higher levels of moral distress because they were not able to carry out their desired actions contributing to optimal patient care. Also, few participants (16 out of the total number) reported ELNEC critical care training.
Several positive significant correlations were found between psychological empowerment and the demographics. In our study, nurses who reported par- ticipating in end-of-life care education in the past year reported higher levels of psychological empowerment in all domains. This is consistent with Corbally et al,25
who conducted a qualitative study examining empow- erment in 93 nurses and midwives. Education for practice was an antecedent to empowerment.
We found that as age and years of critical care experience increased, nurses reported higher levels of empowerment related to competency. Nurses who worked more hours per week were more empowered related to impact. This finding is consistent with results reported by Knol and van Linge5: in their cross-sectional study of nurses using the PEI, they found that registered nurses who worked more hours per week perceived themselves as more psy- chologically empowered.
We found that nurses who reported active col- laboration in end-of-life patient care conferences had higher levels of empowerment related to
self-determination and impact. This finding is con- sistent with results of a mixed-method study using the PEI and interviews done by Williamson14 examin- ing home health nurses’ perception of psychological empowerment. PEI scores were high in this study, and interviews of participants identified collaboration as one of the most important facets of empowerment.
Nurses who scored higher in the following: (1) meaning (attaching greater value to their work), (2) self-determination (feeling higher levels of autonomy), and (3) impact (having greater influence at work) experienced higher levels of moral distress intensity related to deception (situations where they felt unable to address issues related to the impend- ing death of a patient honestly). Nurses who felt more empowered may have been more distressed about not being able to actualize what they perceived as the correct actions.
However, nurses who scored higher in empow- erment related to self-determination experienced moral distress less frequently when participating in situations requiring them to ignore taking actions they felt they should take (individual responsibility). Nurses who perceived themselves as more empow- ered related to their impact experienced moral dis- tress less often when dealing with situations involving the delivery of aggressive care in cases of patient futility (not in patient’s best interest).
Limitations In this study, we did not differentiate between
geographical areas or types of facilities in which nurses practiced, nor did we take into consideration nurses’ sex or culture. The sample was taken from subscribers to the AACN newsletter. This population of nurses may be more apt to feeling empowered and/or feeling greater or less levels of moral distress. The nature of convenience sampling versus random sampling may have limited the study’s findings in terms of predictability and generalizability. The rel- atively low response rate was perhaps due to the large volume of surveys that AACN newsletter sub- scribers are asked to complete.
Conclusion In this study, we sought to examine the rela-
tionship between moral distress and psychological empowerment in critical care nurses related to end- of-life care. The results revealed a significant positive relationship between moral distress intensity and psychological empowerment in the surveyed popu- lation of nurses; however, nurses who perceived themselves as more empowered experienced moral distress less frequently. Another pertinent finding
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was that nurses who participated in end-of-life patient care conferences experienced less moral distress fre- quency in situations related to honestly addressing issues dealing with patients facing impending death.
Nurses more advanced in age and nurses who participated in ELNEC training reported more moral distress intensity related to care that nurses considered futile for the patient. This study indicated that the following nursing demographics were significantly related to higher levels of psychological empower- ment: age, years of critical care experience, work sta- tus, collaboration in end-of-life patient care conferences, level of education, ELNEC training, and end-of-life care education in the past year.
The data supported the relevance of an investiga- tion seeking to correlate moral distress and empower- ment related to select demographics as stipulated in the conceptual framework. No significant correlations were found related to AACN certification or AACN member- ship. Future studies are recommended to address addi- tional demographics such as sex, critical care specialty area, and type of institution where practicing.
Despite the numerous significant positive rela- tionships between the demographics and psychologi- cal empowerment, participants did not experience decreased moral distress intensity in relationship to increased degrees of psychological empowerment. However, the data supported that critical care nurses who perceive themselves as more psychologically empowered experience moral distress less frequently.
This study offers several insights into the contin- uation of a research agenda concerning the potential for decreasing moral distress in critical care nurses related to end-of-life care. Further research examin- ing empowerment as it relates to moral distress is needed to find methods that may decrease moral distress in critical care nurses. Further exploration of how bioethical principles can be more effectively incorporated into nursing education so that nurses may be better equipped to articulate bioethical prin- ciples related to end-of-life care as they apply them to patient care situations in multidisciplinary patient care conference settings is recommended. The results of this study provide relevant data that may increase insight into future interventional studies, potentially aiding in the reduction of moral distress in critical care nurses related to end-of-life care.
FINANCIAL DISCLOSURES None reported.
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CNE Test Test ID A132222: Moral Distress and Psychological Empowerment in Critical Care Nurses Caring for Adults at End of Life Learning objectives: 1. Identify common causes of moral distress in critical care nurses who are caring for dying patients. 2. Describe the concept of psycho- logical empowerment and the 4 cognitions it encompasses. 3. Discuss the study findings as related to the relationship between moral distress intensity and frequency, psychological empowerment, and participant demographics.
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Test ID: A132222 Contact hours: 1.0; pharma 0.0 Form expires: March 1, 2016. Test Answers: Mark only one box for your answer to each question.
1. Which of the following is most commonly associated with increased moral distress in nurses providing end-of-life care to adult patients? a. Nurses’ perceptions that the patient will not benefit from the care being provided b. Nurses’ concerns about prolonging the patient’s suffering c. Nurses’ perceptions that their opinions about end-of-life care are not recognized and valued d. Nurses’ concerns about being able to address the patient’s impending death honestly
2. Based on the study f indings, higher levels of psychological empowerment in all domains would be most likely in which of these groups of critical care nurses? a. Older nurses who work full time b. Nurses who receive end-of-life care education c. Nurses with more years of critical care experience d. Nurses who actively collaborate in end-of-life patient care conferences
3. Which of the following is a subscale used to measure the intensity of moral distress? a. Meaning c. Individual responsibility b. Self-determination d. Impact
4. Which of the following activities was associated with a low level of moral distress intensity, but a high level of moral distress frequency? a. Performing procedures without appropriate informed consent b. Administering and/or withholding life-saving medications for terminally-ill patients c. Following physician orders for unnecessary tests and treatments d. Failing to provide patients and families with adequate education about interventions and therapies
5. According to this study, which of the following nursing demographics were signif icantly related to higher levels of psychological empowerment? a. Age, years of experience, level of education, and critical care specialty area b. Work status, AACN membership, collaboration in end-of-life patient care conferences, and end-of-life care education in the past year c. Age, sex, level of education, and collaboration in end-of-life patient care conferences d. Years of experience, work status, end-of-life care education in the past year, and critical care End-of-Life Nursing Education Consortium training
6. This study sought to determine the existence of a relationship between which of the following 2 variables? a. End-of-life care challenges and levels of moral distress b. End-of-life care challenges and facilitation of psychological empowerment in nurses c. Moral distress intensity and moral distress frequency d. Empowerment and moral distress in critical care nurses
7. Which of the following statements regarding the results of studies of moral distress among critical care nurses is true? a. This study confirmed previous study findings that moral distress frequency is lower than moral distress intensity related to items not in the patient’s best interest. b. This study confirmed previous study findings that moral distress frequency is higher than moral distress intensity related to items not in the patient’s best interest. c. This study confirmed previous study findings that both moral distress frequency and moral distress intensity are typically high among critical care nurses. d. This study contradicted previous study findings about moral distress intensity and moral distress frequency.
8. Active participation in end-of-life care conferences is most likely to inf luence which specif ic facet of empowerment? a. Deception c. Individual responsibility b. Impact d. Meaning
9. The highest level of intensity of moral distress reported in this study resulted from which of the following circumstances? a. Working in situations of low staff numbers, resulting in inability to provide adequate patient care b. Initiating life-saving actions the nurse believes will prolong death c. Assisting a physician the nurse believes is providing incompetent care d. Continuing to care for a hopelessly injured patient receiving mechanical ventilation when no one will discontinue the ventilation
10. Which of the following was identif ied as the highest-ranking obstacle preventing nurses from following the course of action believed to be right? a. Widespread lack of psychological empowerment among nurses b. Increased availability of advanced technology and medications for prolonging life c. Families not understanding the term life-saving measures and its implications d. Lack of standardized nursing education related to appropriate end-of-life care
11. What is the most common phenomenon related to end-of-life care that causes moral distress in critical care nurses? a. Delivering care perceived as not beneficial to the patient b. The gap between nurses having empirical knowledge and not being able to apply that knowledge effectively c. Increased awareness of potential inadequacies in caring for dying patients d. Failing to honestly address issues related to impending patient death
12. Scoring of items on the Psychological Empowerment Instrument were high- est in which 2 subscales? a. Impact and meaning c. Competence and self-determination b. Meaning and competence d. Self-determination and impact
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9. ❑a ❑b ❑c ❑d
8. ❑a ❑b ❑c ❑d
7. ❑a ❑b ❑c ❑d
6. ❑a ❑b ❑c ❑d
5. ❑a ❑b ❑c ❑d
4. ❑a ❑b ❑c ❑d
3. ❑a ❑b ❑c ❑d
2. ❑a ❑b ❑c ❑d
1. ❑a ❑b ❑c ❑d
10. ❑a ❑b ❑c ❑d
12. ❑a ❑b ❑c ❑d
11. ❑a ❑b ❑c ❑d
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Annette M. Browning Caring for Adults at end of Life CNE Article: Moral Distress and Psychological Empowerment in Critical Care Nurses
http://ajcc.aacnjournals.org/Published online © 2013 American Association of Critical-Care Nurses
10.4037/ajcc2013437 143-151 22 2013;Am J Crit Care
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