First ever study of 'moral distress' among nurses in burn unit

Loyola University Medical Center researchers have published the first ever study of emotional and psychological anguish, known as "moral distress," experienced by nurses in an intensive care unit for burn patients.

The study by first author Jeanie M. Leggett, RN, BSN, MA and colleagues is published in the Journal of Burn Care and Research.

Moral consists of painful feelings and associated emotional and mental anguish. It occurs when a person believes he or she knows the ethically ideal or right action to take, but is prevented from doing so because of internal or institutional barriers.

For example, a nurse has to carry out a physician's orders for what the nurse considers to be unnecessary tests and treatments, or witness healthcare providers giving false hope to a patient or family.

Moral distress can result in depression, anxiety, emotional withdrawal, frustration, anger and a variety of physical symptoms. It also can lead to job burnout.

The concept of moral distress among healthcare workers was first identified in the late 1980s, and research on the topic has accelerated during the past decade. There have been studies of moral distress in neonatal and pediatric intensive care units and among genetic counselors, resident physicians and other healthcare professionals. But until now, there had never been a study examining moral distress among nurses in a burn unit.

A burn ICU can be an intense work environment. Many patients suffer significant pain and disfigurement. They may be in the ICU for weeks, and require numerous procedures and surgeries.

"Given the intense and potentially distressing nature of nursing in a burn ICU, it is reasonable to hypothesize that nurses in these settings are likely to experience some level of moral distress," Leggett and co-authors Katherine Wasson, PhD, MPH; James M. Sinacore, PhD; and Richard L. Gamelli, MD, FACS wrote.

The pilot study included 13 nurses in Loyola's burn ICU who participated in a four-week educational intervention intended to decrease moral distress. The intervention consisted of four one-hour weekly sessions. The first session outlined the study aims, definitions of moral distress and related concepts. Session two focused on signs and symptoms of moral distress. Session three dealt with barriers to addressing moral distress. And in session four, nurses were encouraged to identify strategies they could use or employ to deal with moral distress.

The nurses completed a questionnaire called the Moral Distress Scale-Revised (MDS-R) that measures the intensity and frequency of moral distress. They were divided into two groups: One group completed the survey before the intervention, and the other group took the survey after completing the sessions.

Researchers had expected that the group taking the survey after the intervention might have lower moral distress scores. But they found just the opposite: The group taking the survey after the intervention had a median moral distress score of 92, which was significantly higher than the 40.5 median score of the group that filled out the survey before taking the course. (The moral distress score can range from 0 to 336, with higher scores indicating greater moral distress).

Researchers said the reason moral distress scores were higher among nurses who took the survey after the educational sessions could be due to a heightened awareness. "They were able to identify and diagnose moral distress in themselves . . . It is also possible that spending four hours over one month talking about and analysing moral distress raised awareness of the phenomenon."

Six weeks after completing the intervention, both groups took the moral distress questionnaire again, and this time, there were not significant differences in their scores. There also was no significant difference between the groups' scores on a second questionnaire called Self-Efficacy Scale, which is designed to measure a person's effectiveness in coping with daily stressful events.

After each weekly session, nurses completed a written evaluation. "They appreciated the individual sessions and case discussions, felt the session lengths were appropriate and expressed validation of their feelings of moral distress after having participated," researchers wrote. "They indicated that learning the definition of moral distress was valuable, found it helpful to learn that others in similar work environments were experiencing moral distress and appreciated hearing what others do to cope with moral distress. Participants expressed a desire for this type of to continue in the future and for more time to be spent on coping strategies."

Researchers concluded that a larger study, involving more from multiple burn centers, is needed. "The larger study should be refined to develop strategies for implementing effective interventions that become part of the culture and that ultimately reduce moral distress," researchers concluded. "In so doing, effective strategies for dealing with the experienced by this population can be more readily put in place to help cope with it."

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