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Journal of Burn Care & Research:
doi: 10.1097/BCR.0b013e31828c7397
Original Articles

A Pilot Study Examining Moral Distress in Nurses Working in One United States Burn Center

Leggett, Jeanie M. RN, BSN, MA*†; Wasson, Katherine PhD, MPH; Sinacore, James M. PhD§; Gamelli, Richard L. MD*‖

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Author Information

From the *Burn Center; Department of Nursing; Health Sciences Division, Neiswanger Institute for Bioethics; §Department of Public Health Services; and Department of Surgery, Loyola University Medical Center, Maywood, Illinois.

Address correspondence to Jeanie M. Leggett, RN, BSN, MA, Loyola University Medical Center, 2160 S. First Avenue, Maywood, Illinois 60153.

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Moral distress is described as the painful feelings and psychological disequilibrium when a person believes she knows the morally right action to take and is unable to carry it out because of external or internal constraints. It has been studied in intensive care unit (ICU) nurses, but to the best of our knowledge not in burn ICU nurses. A pilot study was performed to gather initial data on moral distress among nurses treating burn victims. Findings from an intervention aimed at decreasing the level of moral distress in these nurses are reported. Nurses (n = 13) were recruited from one U.S. burn ICU and were randomized into two groups. A separate sample pretest post-test design was used. Group A completed the Moral Distress Scale-Revised (MDS-R) and Self-efficacy (SE) Scale before a 4-week educational intervention involving weekly 60-minute sessions, and Group B completed both scales afterward. Participants also completed written evaluations after each session. The MDS-R and SE Scale were readministered to both groups 6 weeks after the intervention was completed. Given the size and distribution of the sample, nonparametric data analyses were used. The MDS-R median score for Group B (92.0) was significantly different statistically from Group A (40.5) with P = .032 directly after the intervention was completed. No significant difference was found in the median SE scores between Group A (34.5) and Group B (34.0; P = .616). The median for Group B was 69 and Group A was 60.5 (P = .775). At the 6-week follow up, the difference between the two groups was no longer observed. Defining and discussing moral distress may have contributed to increased awareness and higher levels of moral distress in Group B directly postintervention. The changes in moral distress levels postintervention and at the 6-week follow up highlight the need to examine the intervention in a larger sample.

Moral distress has been defined in multiple ways. Jameton1 described it as painful feelings or psychological disequilibrium caused by a situation in which a person believes she knows the ethically ideal action to take, but cannot carry out that action because of institutionalized obstacles; eg, lack of time, supervisory support, medical power, policy, or legal limits.2 Wilkinson3 stated moral distress is the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision. The American Association of Critical Care Nurses describes moral distress as knowing the ethically appropriate action to take, but being unable to act upon it or acting in a manner contrary to your personal and professional values which undermines integrity and authenticity.4 Moral distress is painful feelings and the associated emotional and mental anguish as a result of being conscious of a morally appropriate action which, despite every effort, cannot be performed owing to organizational or other obstacles.1,5 Core features of these definitions include painful feelings and psychological disequilibrium or anguish when a person believes she knows the morally right action to take in a situation and is unable to carry it out because of external or internal constraints.

Initial moral distress is the sensation experienced when an ethically sensitive nurse first encounters a moral situation within a poor ethical climate. It is characterized by feelings of anxiety and guilt that possibly give rise to negative consequences.1,3 If the initial moral distress is not acted upon, reactive moral distress—or “moral residue”—remains with the nurse and may build up over time.6,7 The level of moral distress can increase with each challenging case and fail to return to its prior baseline levels. Such an increase in moral distress levels is termed the “crescendo effect.”8

Moral distress has been measured in multiple populations of health care providers, most notably nurses. Concern about the occurrence of moral distress in nurses was initially related to a fear of “burn-out” in critical care nurses. Corley9–12 empirically examined the phenomena of moral distress in critical care nurses and developed a Moral Distress Scale (MDS) to measure it. Subsequent research has demonstrated that nurses experiencing moral distress are more likely to make errors, change positions, experience desensitization to the moral aspects of care, or leave the profession altogether, which poses challenges for the profession, specific health care setting and the individual nurse.13,14 Corley’s MDS has become a standardized tool for measuring moral distress in critical care nurses and has been adapted for or used in other populations, including Neonatal Intensive Care Unit (ICU) nurses,15–18 Pediatric ICU nurses,19,20 genetic professionals,21 surgical residents,22 medical residents,23,24 and other healthcare professionals.25–32 As recently as 2012, Wocial and Weaver33 developed and tested a moral distress thermometer in an attempt to provide a more objective measure of the very subjective, often not directly observable, experience of moral distress.

To the best of our knowledge, there is no empirical research on moral distress in burn ICU (BICU) nurses, leaving a significant gap in the field. These nurses care for patients who have been in disfiguring and painful accidents, may have selfinflicted injuries, or may have been harmed by another person. This care can be demanding and recovery extremely lengthy, with multiple interventions and surgeries over time. Given the intense and potentially distressing nature of nursing in a BICU, it is reasonable to hypothesize that nurses in these settings are likely to experience some level of moral distress. An institutional review board–approved pilot study was performed at one verified United States Burn Center to gather data on moral distress among nurses treating burn victims. Verification is a joint program of the American Burn Association and the American College of Surgeons. To achieve verification, a burn center must meet rigorous standards for organizational structure, personnel qualifications, facilities resources and medical care services. Burn center verification is a voluntary program and provides a true mark of distinction for a burn center and is an indicator to government, third-party payers, patients and their families, and accreditation organizations that the center provides high quality patient care to burn patients from the time of injury through rehabilitation.34) This article reports the findings from a pilot intervention designed to decrease the level of moral distress in these nurses and to evaluate the effectiveness of such an intervention.

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Two paper-and-pencil instruments were used in this study. One of these was a revised form of the MDS (MDS-R), based on Corley’s original 38-item scale and reduced to 21 items.35 The scale presents a set of hypothetical clinical moral dilemmas which the respondent may have experienced. Two examples of these are witnessing diminished patient care quality due to poor team communication and having to provide suboptimal care due to pressures to reduce costs. For each of the dilemmas, respondents rate how frequently the event occurs for them ranging from 0 (never) to 4 (very frequently). They also rate how disturbed they are by the event from 0 (none) to 4 (a great extent). The frequency and disturbance ratings are then multiplied and summed over all 21 events. Hence, the scale score can range from 0 to 336 with higher scores indicating greater moral distress.36 Prepublished results of an evaluation of the MDS-R have shown good reliability (Cronbach α = .88) and construct validity (Hamric, personal communication).

The second instrument in this study was the Selfefficacy (SE) Scale, which is designed to measure perceived self-effectiveness in coping with daily stressful life events. SE is an optimistic belief37 that one can perform novel or difficult tasks, or cope with adversity, in a variety of areas of human functioning.38 Schwarzer and Jerusalem38 state, “Perceived self-efficacy facilitates goal-setting, effort investment, persistence in face of barriers and recovery from setbacks. It can be regarded as a positive resistance resource factor.” The authors note that perceived SE is an operative construct and therefore related to subsequent behavior, making it relevant to clinical practice and behavior change.

The SE Scale presents statements to respondents that describe successful coping and an internal-stable attribution of success. For example, one item is “I can always manage to solve difficult problems if I try hard enough.” The scale consists of ten items with a response scale going from 1 (Not at all true) to 4 (Exactly true). The responses to all items are summed for a scale score that ranges from 10 to 40, with higher scores indicating greater perception of SE. Schwarzer and Jerusalem38 report that the SE Scale has good reliability with Cronbach α ranging from .76 to .90 among a series of studies. The authors also report that criterion-related validity has been shown in that positive correlations of SE were found with favorable emotions, dispositional optimism, and work satisfaction. Negative correlations were found with depression, anxiety, stress, burnout, and health complaints. The purpose of using both the MDS-R and the SE scales was to explore the idea that nurses’ distress in caring for patients in a burn unit is related to matters of morality rather than psychological coping.

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Study Setting

From 2008 through 2011, one verified United States burn center had 2542 admissions of which approximately 40% were children. The severity of the burns ranged from 0% (inhalation injury only) to 96% TBSA and the average length of stay was 7.95 days with a range of 1 day to several months. Of these admissions, 184 were soft tissue admissions, such as necrotizing fasciitis (flesh-eating disease), and another 105 were toxic epidermal necrolysis syndrome (TENS).

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Phase One

The researchers were unable to locate any published literature on moral distress in BICU nurses. Therefore, in order to develop an appropriate and effective strategy for addressing and potentially decreasing moral distress in BICU nurses, researchers drew on the limited published literature on interventions in other nursing or healthcare populations to develop open-ended questions and conducted interviews with key informants from four other BICU in the United States. As reflected on the American Burn Association Web site,39 these were all verified burn centers. Key informants confirmed these burn centers were comparable in their patient populations, caring for both adults and children, and had at least several hundred admissions per annum. Interviews with seven key informants across the four burn centers included three nurse managers, one charge nurse, and three staff nurses. The interview questions included the informant demographics: current position, years of nursing and BICU nursing experience (Table 1). Interviews also probed whether informants experience stress in the workplace, whether they knew the term “moral distress” and how they would define it, what type of cases cause moral distress, unit-specific or institutional strategies to address moral distress, and any additional strategies they thought were needed to address moral distress. The interviews were audio taped and transcribed verbatim. The data was analyzed using grounded theory and constant comparison methods. Grounded theory is the method of choice when little is known about a phenomenon. It involves analyzing qualitative data, and allowing themes and categories to emerge, rather than imposing themes on the data.40–42 Constant comparison methods involve analyzing the data as they are acquired, rather than waiting until all the data are collected. This approach is particularly useful when there is limited information in a given area because it allows the researchers to incorporate new themes that emerge from the data into future interviews. Conceptual categories and common themes were identified through the data analysis and informed the development of the study intervention.

Table 1
Table 1
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Phase Two

This phase of the study employed a separate sample pretest post-test design (SSPPD) using two validated tools: the SE Scale and MDS-R by Hamric and Blackhall.43 The MDS-R was used to detect the intensity and frequency of moral distress and the SE Scale measured the levels of SE in these nurses. The SSPPD is used when an intervention is implemented in an action, ie, real life, setting and the separation of participants in the intervention and control groups cannot be adequately maintained. Since all research participants were nurses working in the same BICU, it was reasonable to postulate that information from nurses receiving the intervention would eventually leak over to those assigned to the other group, weakening the difference between the two groups. The SSPPD prevents this problem. As Figure 1 indicates, all nurses received the intervention. However, half of the nurses were randomly selected to provide data on moral distress and SE before the intervention occurred and the other half did so afterwards. SSPPD is a quasi-experimental design and the two major threats to internal validity described by Cook and Campbell44 are history (eg, a required change in clinical practice occurring during the intervention period) and attrition. Given the ongoing stability of this BICU and its staff, these threats had a very low probability. To assess the effect of the intervention over time, both groups completed the MDS-R and SE Scale again 6 weeks after the intervention finished.

Figure 1
Figure 1
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An educational intervention to address moral distress was developed based on the limited literature in other populations and key informant interviews.45,46 It involved one 60-minute session per week for 4 weeks. Group A completed their scales the week before the intervention began and Group B completed them the week after the intervention ended. Sessions were offered for both day and night shift nurses, refreshments were provided and participants were compensated $25 per session. Participants were permitted to miss one session and remain in the study. Session one outlined the study aims, definitions of moral distress and related concepts, and case studies for discussion. Session two focused on signs and symptoms of moral distress and included brainstorming from the group. Key informant interview data was reviewed, as well as root causes and effects of moral distress, a case study, and ethical issues related to moral distress (particularly end-of life, quality of life, and futility). Session three dealt with barriers to addressing moral distress, currently published approaches to addressing moral distress and further discussion. Session four encouraged the nurses to identify strategies they use or could employ to deal with moral distress individually and in the BICU.

The MDS-R and SE Scales were scored according to their respective protocols and when examined the distributions of the scales were found to be notably skewed. Other scaled variables (eg, years in nursing) were also found to be skewed. Hence, tests of statistical significance with these variables were conducted with the Mann–Whitney U test. Differences among categorical variables (eg, gender) were tested with the Pearson χ2 test for association.

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In Phase One, qualitative analysis of the key informant interviews showed respondents described feeling general stress regularly, as a result of the type of work they do. Participants described a need for there to be a “listening ear,” but found it difficult to talk about the stress they felt at work with family, and as a result some reported feeling withdrawn and isolated at times.

During the interviews, participants stated it was important that there be some kind of organized debriefing in response to morally distressing patient situations. They expressed varying opinions about whether debriefings should be proactive and ongoing, or reactive to a particular situation or case; rather, those views varied from person to person. Several respondents indicated that their facilities offered some type of program to help staff deal with stressful situations; most of these programs were part of the institutional Employee Assistance Program, and one hospital had a “critical incident stress management team” composed of individuals experienced in stress management that provide a sounding board and resource for the staff at the entire hospital. Several respondents described hospital-sponsored burn survivor programs as another resource that helped address their moral distress, because staff is able to see patients after their intense and sometimes lengthy hospital stays and observe their reintegration into everyday life. The results of the key informant interviews were used to inform the content of intervention sessions that were subsequently conducted with the BICU nurses that participated in the study.

Phase Two of the study was performed in one verified United States burn center. Fourteen nurses enrolled in the study, and 13 nurses, representing 29% of the BICU nursing staff, completed the study.

Table 2 provides demographic information for the participants. Groups A and B did not vary significantly with regard to race/ethnicity, religion, sex and age but did have noted differences in experience level. Group B participants had a median experience level of 13 years, while for Group A it was 3.5 years. No statistically significant differences were identified with any demographic data collected from the two groups. With regard to previously experienced moral distress, two nurses reported having considered leaving a position due to moral distress, though none had left. None reported considering leaving their current position.

Table 2
Table 2
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Directly after the intervention was completed, a statistically significant difference in the medians of the MDS-R scores was observed (U = 36, z = 2.14, P =.032). They were 92 for Group B and 40.5 for Group A, respectively. This difference was contrary to what was expected because the nurses in Group B showed a higher level of moral distress after the intervention. The medians for the SE scores were 34 for those in Group B and 34.5 for those in Group A. This difference was not statistically significant (U = 24.5, z = 0.50, P =.616).

The difference in MDS-R scores that was observed at the completion of the moral distress intervention was not observed at the 6-week follow up. The follow up median for Group B was 69 and for Group A was 60.5. This difference was not statistically significant (U = 23 z = 0.268, P =.775). The follow up medians for the SE scores were 33 and 36.5 for Group B and Group A, respectively. Similar to the finding directly after the educational intervention, this difference was not statistically significant (U = 32, z = 1.58, P =.114).

Open-ended evaluations were completed by study participants in both groups after each of the four intervention sessions (Table 3) and at the conclusion of the study (Table 4). Participants reported in their evaluations that 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. 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 intervention to continue in the future and for more time to be spent on coping strategies.

Table 3
Table 3
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Table 4
Table 4
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It was notable that Group B had a statistically significant higher median MDS-R score than Group A after the intervention, which was designed to address and potentially decrease moral distress in this sample. This phenomenon was observed in another interventional study on moral distress in Neonatal ICU nurses.45 There are several possible explanations for the noted difference between the two groups. It is possible that participants learned through the course of the study intervention what to call the feelings they had been experiencing, had learned a new “language” as a result of participation in the sessions, and were therefore better able to articulate feelings that existed all along. Group B may have been experiencing moral distress but did not have a “name” for it. After the intervention, they were able to identify and diagnose moral distress in themselves and, thus, it was more prevalent than in Group A, who completed the scales prior to the intervention. It is also possible that spending 4 hours over 1 month talking about and analyzing moral distress raised awareness of the phenomenon, which contributed to higher levels in Group B than in Group A.

Group B study participants also have greater work experience, ie, number of years, in nursing overall and in the BICU than do the Group A participants as indicated in Table 1. While this difference did not reach statistical significance, it may contribute to a crescendo effect in Group B as described by Epstein and Hamric.8 This crescendo effect could help explain the higher levels of moral distress in Group B. Further investigation with a larger sample of BICU nurses is necessary to evaluate this trend.

When the MDS-R was administered to both groups 6 weeks following the last intervention session, scores for Group A increased slightly and scores for Group B decreased slightly, but the measured changes for both groups were not statistically significant. It is postulated that both groups’ scores changed slightly because the participants in each group had additional time to process the information that had been learned through the course of the intervention sessions and had become more aware of moral distress. Group A had also completed the intervention and it is perhaps not surprising that its scores were more similar to Group B postintervention.

As for ways of coping with moral distress, this pilot study was not conclusive but raises possibilities for further exploration. In the written evaluations of the intervention sessions, nurses indicated that learning definitions of moral distress and related concepts, talking and sharing about moral distress and knowing that others felt the same way were all helpful approaches.8,25 They also appreciated hearing how others dealt with or tried to prevent moral distress. These anecdotal approaches included finding a person they could talk to regularly about hard cases, ie, friend in a related field or family member, getting together with colleagues either to “debrief” after a tough shift or socially, and learning to “switch off” or compartmentalize from work when leaving the unit.30 Interviews with other burn center nurses in Phase One highlighted a range of different approaches including having annual retreats for nursing and medical staff which may include burn survivors, having regular debriefing sessions on the unit (whether proactive or reactive to morally distressing cases),47 implementing mentoring programs between seasoned and new nurses, and having opportunities for all the staff to socialize together which fosters team building.

The American Association of Critical Care Nurses recommends four steps in addressing moral distress: ask whether you are experiencing moral distress and/or showing signs of it; affirm your distress and a commitment to take care of yourself; assess the source of your distress and determine its severity; act to implement strategies that initiate changes to address moral distress.4

It should be noted that this study had some limitations. The study population was numerically small, and was limited to a single burn center as it was a pilot study in a novel area of research. It is also very difficult to carry out interventions for an ICU since it never closes and patient care coverage is always needed, which can present challenges to study participation and can create an additional source of stress for participants. However, the results of this study appear to parallel results of studies in other intensive care settings such as Neonatal ICU,16 Pediatric ICU,19 and Medical ICU48 where researchers found that educating ICU nurses about moral distress helps them learn to understand and deal with it more effectively.

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The impacts of moral distress in nurses during the provision of care, particularly in critical care settings, is well documented and can result in a wide variety of human reactions, including depression, anxiety, emotional withdrawal, frustration, anger, and a variety of physical symptoms.49,50 This pilot study, which was conducted in one verified United States burn center, demonstrates that nurses working in the BICU experience moral distress related to their work. The findings raise questions regarding possible contributing factors to moral distress levels in these nurses (ie, demographic characteristics such as years in nursing and in burn nursing). In addition, the postintervention gap in median moral distress scores in Group B when compared to Group A, and the change in these levels after 6 weeks, as well as the dissonance between these levels and the largely positive evaluation feedback, requires further examination with a larger sample.

As noted by Hamric, “…many studies have very small and targeted respondent groups, primarily in nursing. As a result, the existing knowledge is fragmented in some important respects.”14 The subject of this study would be well-served by a larger and more broad-based study involving multiple burn centers and a larger population of nurses working in this important area of nursing. Additionally, 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.51 In so doing, effective strategies for dealing with the moral distress experienced by this population can be more readily put in place to help cope with it.

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© 2013 The American Burn Association


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