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Freirean Conscientization With Critical Care Nurses to Reduce Moral Distress and Increase Perceived Empowerment

A Pilot Study

Bevan, Nancy A. PhD, APRN, ACNS-BC; Emerson, Amanda M. PhD, RN

Author Information
doi: 10.1097/ANS.0000000000000307

Abstract

NURSES IN the United States and globally are highly susceptible to moral distress, which arises in part from long-standing hierarchies of power embedded at all levels in health care systems. The relationship between moral distress and disempowerment is mutually reinforcing, with disempowerment in decision making linked to moral distress for nurses, just as moral distress is linked to nurses' further sense of disempowerment in patient care.1,2 Although the connection between perceptions of powerlessness and the experience of moral distress in nursing is well-documented, there has been much less study to understand why nurses remain vulnerable to powerlessness or to find effective ways to break that link.2,3

Nursing's relative lack of structural power in health care has led some to argue that nurses represent an oppressed group.4,5 Given their level of training, crucial roles in the health care continuum, and sheer numbers, nurses as a group remain surprisingly disempowered, and this is true despite the many examples of individual nurses who attain positions of influence. In keeping with what theorists argue about oppressed groups in general, nurses may lack insight into the collective nature of their oppression and thus may struggle ineffectually to overcome it on their own.4

Freirean pedagogy and the problem-posing approach refer to a group-learning process developed by the Brazilian educator Paolo Freire to assist members of socially and economically oppressed groups to recognize and understand their position vis-à-vis systems and structures that dominate them and provide support as they collectively formulate self-empowering responses.6 Ours is the first published intervention study that attempts directly to address the role of oppression in the development of moral distress in nursing. The aim of this study was to pilot an intervention modeled on Freire's problem-posing framework with nurses who suffered moral distress.6 We sought to learn whether the intervention was effective in increasing nurses' consciousness of the conditions that lead to disempowerment and moral distress in the workplace and their potential power to alter those conditions.

Statement of Significance

What is known or assumed to be true about this topic:

Nurses in the United States and globally are highly susceptible to moral distress. There is strong evidence that links powerlessness arising from structural hierarchies embedded in health care to moral distress in nursing. Nursing's relative lack of structural power in health care has led some to argue that nurses represent an oppressed group, and like other oppressed groups, nurses may lack insight into their oppression and struggle ineffectually to overcome it on their own. Freirean pedagogy and the problem-posing approach refer to a group-learning process developed by the Brazilian educator Paolo Freire to assist persons who are socially and economically oppressed in coming to recognize and understand their position vis-à-vis systems and structures that dominate them and to provide support as they collectively formulate self-empowering responses. Currently, there are no interventions that address the role of oppression in the development of moral distress in nursing.

What this article adds:

This problem-posing educational intervention was feasible and acceptable. From the perspective of Freirean theory, participants gained knowledge about the role that oppression played in their moral distress, and how and why they had been suffering alone and mostly in silence. Nurses discovered ways to work together to disrupt oppression, set goals, and develop action projects based on weighing what they thought would work and not work. The study showed that a process of critical reflection, critical motivation, and critical action could help nurses develop tools not only to prevent moral distress from happening to them in the future but also to teach and mentor others. Thro-ugh successful conscientization, nurses would empower themselves to join forces in raising their moral voices in situations in which they might formerly have felt alone and silenced.

BACKGROUND

Research suggests that the inability to manage moral distress leads to harmful physical and psychological consequences for nurses, including disengagement and withdrawal from patient care, burnout, and leaving the profession.2 Nurses who have suffered moral distress often describe their experiences in terms of a lack of power and autonomy in decision making related to patient care.2,7 The lack of power that nurses describe in moral distress situations reflects hierarchical organizations of power. In health care contexts, nurses often find themselves carrying out the care plans and orders of others—physicians, specialists, ethics boards—sometimes against their own clinical and ethical judgment.

Iris Young's5 theory of oppressed groups is relevant to nurses' experience of structural subordination in hospitals and other health care settings. In Young's theory, group oppression refers to the restraint or diminishment of social group's power through organizational or structural factors. Young argued that groups experience oppression under 5 different conditions: exploitation, marginalization, powerlessness, cultural imperialism, and violence. All 5 conditions of group oppression have been linked in research to the experience of nurses in workplace structures, including vertical relationships (ie, administrator- or physician-originating oppression) and horizontal relationships (ie, other nurse-originating).8,9 According to Young's theory, group oppression creates feelings of invisibility, devaluation, and objectification, and inflicts further damage when members of the oppressed group assimilate the oppressors' views of their value and abilities.5,6 Oppressed group behaviors may result, in which the oppressed group internalizes attitudes of the dominant group, isolating and intimidating its own.

In 1983, Roberts4 first associated oppressed group behaviors with nursing in an article in this journal that laid out horizontal violence and workplace bullying in nursing as behaviors predicated on nurses' status as an oppressed group. Since that time, lateral violence and other oppressed group behaviors in nurses have been reported regularly in studies of nursing.10,11 Responding transformatively or constructively to the experience of oppression in nursing is important: nurses who remain unconscious of their oppressed status are likely to experience moral distress when they perceive their voices to be unheard and their perspectives ignored. Perhaps worse, out of frustration and resentment, they may behave in ways that contribute to moral distress in others.

Theoretical framework

We used Freire's Pedagogy of the Oppressed as a theoretical framework to guide aims, development, and delivery of a small-group intervention to build awareness in nurses of the oppressive conditions that cause moral distress in nursing and as a source for techniques to formulate empowering responses.6 Freire developed problem-posing education as an educator teaching literacy to sugarcane workers in Brazil. A group-learning process, problem-posing education uses everyday experiences to produce collective awareness of shared conditions among members of an oppressed group. Problem posing is transformative in that it emancipates the group, allowing members to recognize their collective power to bring about change and teaching them tools for accomplishing that change.6,12 A problem-posing approach begins with a 2-step process that involves codification, or a group's generation of stories that encode the real nature of their oppressed situation, and decodification, the groups' breaking down of their moral distress stories to illuminate the role that power and oppression play.13

The goal of problem-posing education and the overarching aim of the intervention we describe are to inspire a continual cycle of reflection and action, or praxis. Freire used the term action-praxis to describe the process of reflecting on what worked or did not work in a situation and choosing subsequent actions based on critical or questioning dialogue.14 All praxis is oriented toward conscientization, which names Freire's notion of a dynamic, transformational, active process toward human liberation that is premised on a moral belief in the equality and dignity of all people. Conscientization is thus more than just becoming conscious of disempowerment. The process of conscientization, including the problem-posing education method that promotes it, comprises a group's growing self-awareness of the conditions in which it works and increasing power to act together to change those conditions. Both transformational and social, conscientization often entails the development of skills to challenge disempowering relationships by applying collective pressure on the systems that support them.6

Aim and hypothesis

In keeping with conscientization, the study aim was to use a structured experience of story sharing and problem posing to lead nurses with personal experience of workplace moral distress (a) to identify the roots of their moral distress in group oppression and disempowerment and (b) to experience social connectedness as a motivation for and source of empowerment to act to change the conditions of their oppression. Our hypothesis was that nurses would experience less moral distress and more empowerment as a result of participating in a problem-posing intervention.

STUDY DESIGN

Design

A mixed-methods pre/postdesign was used, following what Creswell refers to as the parallel database convergence approach.15 The design includes simultaneous collection and analysis of qualitative and quantitative data, followed by a merging of results to evaluate for similarities (convergences) and differences (divergences).15 Because the study aimed to produce social change and was built on the moral assumption that redressing inequitable distributions of power in health care organizations is a worthwhile project for research, the design is also transformational.15,16

Sample/participants

We recruited 13 critical care nurses from a single metropolitan area in the Midwestern United States. Recruitment letters were posted on the Web site of a local chapter of the American Association of Critical-Care Nurses. Eligibility to participate was employment as a critical care nurse for at least 1 year and having experienced, within the past year, work-related moral distress. Participants were recruited over 2 months. After the first month, online recruitment was supplemented with snowball sampling. Recruitment ended after 13 participants were enrolled in the study. We determined that the sample size would be sufficient due to the small-group nature of the intervention and the abundance and variety of data to be collected from participants. Reasons given by prospective participants who declined to enroll included not being able to take time off from work, too much time investment, and other commitments. No one refused to participate in the study due to lack of interest, and no participants were lost during the study.

METHODS AND PROCEDURES

Intervention

In consultation with an expert in Freirean pedagogy from the Freirean Institute in Lancashire, United Kingdom, the conscientization curriculum was designed and then tested and refined from January through July 2017. The first author and the consultant rehearsed 3 conscientization sessions with 7 nursing students in March 2017. The eventual curriculum included three 4-hour sessions (see Supplemental Digital Content Table A, available at: http://links.lww.com/ANS/A19), each with learning objectives and activities that aligned with the 3 phases of Freire's pedagogy: critical reflection, critical motivation, and critical action.6,16

Measures

To achieve the mixed-methods study aims, we generated a variety of data using diverse methods. The primary qualitative data in the study came from participants' written moral distress stories, audio recorded discussions, diagramming exercises, and worksheets. Postintervention, the first author conducted semistructured, individual interviews with the participants. The interview guide included 14 questions related to program acceptability and perceived learning.

Quantitative data were scores on instruments that measured moral distress, perceived psychological empowerment, and structural workplace empowerment: the Moral Distress Scale—Revised (MDS-R), the Psychological Empowerment Scale (PES), and the Conditions of Work Effectiveness Questionnaire—II (CWEQ-II) (Table 1). The MDS-R is a 21-item, Likert scale survey that measures frequency (f) and intensity (i) of moral distress for a total moral distress score (f x i).17 The first author divided ranges of MDS-R total moral distress scores into quartiles (see note, Table 1), and frequency and intensity subscales were each leveled into thirds. Testing of the MDS-R has shown good validity (>0.85) using Cronbach α.17 The PES is a 12-item Likert scale survey that measures perceived level of psychological empowerment.18 Divided into 4 subdimensions—meaning, competence, self-determination, and impact—the PES can be summed for a total empowerment score, which was leveled into thirds for this study. Reliability and validity of the PES have been established.18,19 To measure perceived structural empowerment in the workplace, the CWEQ-II was administered. A 19-item, Likert scale survey, the CWEQ-II provided measurement in 6 subscales. These were summed for a total empowerment score, which was leveled into thirds for this study.20 Good construct validity for the CWEQ-II has been established through confirmatory factor analysis and high correlation between total score and global empowerment score.20,21

Table 1. - Related Samples Wilcoxon Signed Rank Tests for MDS, PES, and CWEQ-II
Scales Preintervention (n = 13) Postintervention (n = 13) P
MDS Total 132 111 .00a
MDS Frequency 38 34 .03a
MDS Intensity 65 72 .00a
PES Total 60 61 .07
PES Meaning 14 16 .046a
CWEQ-II Total 72 70 .06
Abbreviations: CWEQ-II, Conditions of Work Effectiveness Questionnaire—II; MDS, Moral Distress Scale; PES, Psychological Empowerment Scale.
aP < .05; ranges for MDS-R Total = 0 to 83 (nonslight), 84 to 167 (medium), 168 to 252 (moderate), and 253 to 336 (severe); MDS-Frequency and Intensity = 0 to 27 (low), 28 to 56 (medium), and 57 to 84 (high); PES = 12 to 35 (low), 36 to 60 (medium), and 61 to 84 (high); and CWEQ-II = 10 to 33 (low), 34 to 62 (medium), and 63 to 95 (high).

Ethical considerations

Participants gave written informed consent, including consent to be recorded, during their first session and were given opportunity to ask questions about the purpose and potential risks and benefits of taking part in the study. Participants were informed of the importance of maintaining one another's confidence by not repeating what they heard and were advised that they could withdraw from the study at any time. The institutional review board at the University of Missouri-Kansas City granted approval for all study procedures.

Data analysis

Qualitative: Moral distress stories and postintervention interviews

Thematic and structural analysis was performed on the moral distress stories and thematic analysis was used to discern patterns of meaning in the interviews. First, we applied Saldaña's technique of descriptive content analysis, which uses a streamlined coding approach to capture important ideas in the data through words or short phrases.22 After the initial coding of the moral distress stories, the first author reread and reduced codes. The first round of coding produced 157 codes. A second round, in which duplicates were removed and like codes combined, reduced the number to 35. The first author consolidated codes into themes, and the first and second authors discussed and agreed on 4 main themes. These were discussed further with 4 additional readers associated with the project. The postintervention interviews to assess acceptability of the intervention were analyzed item-by-item for patterned responses across interviews, which were labeled, grouped, and tallied by the first author and reviewed by the second, with representative quotes set aside for reporting.

Second, to gain a better notion of the plotted aspect of the moral distress stories—their narrative shape—structural analysis of the stories was performed using categories from Labov's classic approach.23 Labov's method, which has been adapted by subsequent developers of narrative analysis, including Mishler24 and Riessman,25 focuses on clauses or segments of a story and the work they accomplish in the structure of the story. The first author segmented each story into constituent clauses and labeled and plotted the clauses according to Labov's 6 functional elements of narration: the Abstract (AB), or summarized preview of the story; Orientation (OR), the story's time, place, and participants; Complicating Action (CA), or the plot, including sequences and turning points; Evaluation (EV), a storyteller's commentary on the complicating action of a story; Resolution (RE), a solution or ending disposition of the problem; and the Coda (CODA), the summing up and delivery of the listener to the present.25 Story segments were mapped to visualize structural patterns, and those patterns were analyzed for function and meaning within and across the stories.

Quantitative: Demographics, retention, and intervention effects

Means and frequencies were calculated for demographic data and retention. Spearman correlation coefficient (α = .05) was used to assess relationships in demographic data (age, years of experience, and years in critical care among others) and mean pre- and postintervention MDS-R, PES, and CWEQ-II scores. To determine differences in pre- and postintervention moral distress levels, psychological empowerment levels, and structural empowerment levels, related samples Wilcoxon signed rank tests for nonparametric samples were calculated for pre- and post-MDS-R mean total scores, MDS-R mean frequency scores, MDS-R mean intensity scores, pre- and post-PES mean scores, and pre- and post-CWEQ- II mean scores. Individual items from the MDS-R, PES, and CWEQ-II that corresponded with prevalent themes in the moral distress stories and postintervention interviews were also scored and evaluated separately. All statistical analysis was performed using IBM SPSS, Version 24.

Convergence/divergence of data

The mean MDS-R, PES, and CWEQ-II scores and results from Wilcoxon signed rank tests were compared and contrasted with themes from the moral distress stories and postintervention interviews for agreement and disagreement in general tendency.

Rigor and trustworthiness

Rigor or trustworthiness in the study was a priority of the researchers, beginning with the first author's formal consultation with a Freirean content expert to ensure the fidelity of the curriculum design to Freirean pedagogic theory. In analysis of the moral distress stories and postintervention interviews, credibility of findings was enhanced by data source triangulation (ie, with thematic findings from interviews and results of statistical tests) and investigator triangulation (ie, theme review by the second author and readers).26 Reflexive journaling by the first author throughout the study fostered self-awareness and helped prevent confirmation bias during coding and theming.25,27 Rigor in the quantitative analysis was supported by use of instruments with proven validity and reliability.

FINDINGS AND ANALYSIS

The conscientization intervention to address moral distress was implemented in 3 sessions, October 10, 17, and 24, 2017, with postintervention individual interviews completed November 6 to 17, 2017. The sample included 13 female critical care nurses from a large metropolitan area in the Midwest United States. All participants were white and ranged in age from 24 to 61 years. Nursing experience was 2 to 38 years. Three nurses had associate degrees (ADN), 8 had bachelor's degrees (BSN), and 2 held master's degrees (MSN). Retention was 100%; however, not all 13 participants attended all 3 sessions. There were 7 participants in session 1, 11 in session 2, and 13 in session 3. Spearman rank correlation coefficient tests showed no correlation between the number of sessions attended (2 vs 3) and any other variable, including scores on the MDS-R, PES, and CWEQ-II.

Qualitative findings

Thematic analysis

Nurses wrote out their moral distress stories during the first session. In Freirean terms, these stories codified the experiences of oppression that the nurses then worked together in subsequent sessions to unpack or decodify and in response to which they developed action plans (ie, praxis). The most prominent themes from the moral distress stories (Table 2) included sources of moral distress, responses of the nurse, power dynamics, and lack of resolution.

Table 2. - Themes, Selected Codes, and Quotes From Moral Distress Stories
Themes Codes Quotes
Sources of moral distress Futility of care clinical situations “Patient in hospital for multiple weeks and not really doing anything to improve quality of life.”
Prolongation of life “Her [the patient] family demanded everything be done for her, and she was a full code.”
Multiple invasive procedures “[The family] continued life prolonging treatments, multiple cardiac arrests, and Continuous Renal Hemodialysis Therapy.”
Unsafe care/unsafe situation “I was told that the patient was admitted with respiratory distress and that the ED attempted to increase the size of the patient's tracheostomy .... The next morning the patient's tracheostomy became dislodged and the patient arrested.”
Response of the nurse Nightmares “I had nightmares for a long time.”
Physiological “I thought I was going to throw up.”
Anger “I was so upset that I had the manager take over care of my patients.”
Shame “I felt terrible that I had to restrain a patient at the end of her life.”
Outrage “I felt terrible that they [the family] didn't have enough respect for their father to take care of him.”
Guilt “I felt guilty working on a patient to revive her and she [the patient] doesn't want to be revived.”
Regret “My moral distress is that I regret placing the patient on bi-pap and restraining them.”
Helplessness “I felt helpless.”
Power dynamics Family “I believe the patient is wanting to die but the family will not let her go.”
Family “The daughter would call up the physicians and they would take orders from her!”
Physician “The physician proceeded to yell at me and refused to change the code status.”
Organization “Organization [hospital administration] sided with the family [against patient wishes] we [the hospital] were promised a big donation from daughter.”
Lack of resolution Nurse advocacy “The nurses were left to fill in the answers and the gaps the physicians refused to talk about.”
“After a week of asking for it, Palliative care still wasn't ordered.”
“Patient code status was changed to DNR after 3-4 months of ethics and multiple meetings with daughter, administration.”

Sources of moral distress

This theme was exemplified in accounts in which futility of care, aggressive care against patients' wishes, and unsafe care were prevalent. The source of moral distress theme was evident, for example, in one nurse's recollection of an older adult patient with end-stage renal failure, who “wasn't going to recover, but we kept doing treatment on her anyway.” Another nurse's story described how she relayed to the attending physician a patient's request to have his or her status changed to do-not-resuscitate, only to be “yelled at.” The request was ignored. A respiratory code event occurred the next day, cardiopulmonary resuscitation was performed, and after further suffering, the patient arrested and died. The nurse's coda to that story: “I'll never forget the phone call I made to the patient's daughter that morning as we discussed what the patient would have wanted.”

Response of the nurse

The second theme, response of the nurse, arose in descriptions of how moral distress felt to nurses and their struggles to cope with their feelings. One nurse's fragmented notes about the aftereffects of her moral distress experience highlighted how central the sense of helplessness could be in nurses' attempts to cope: “Dreams—Reworking—Back to work—Sent to unit 1st day crying! No control.” In another story, a nurse described learning from a patient's girlfriend that the patient was verbally and physically abusive toward her at home. The nurse and her supervisor referred the girlfriend to the chaplain and provided resources. The patient killed the girlfriend the day he was discharged. The nurse's response concisely recorded the anguish of disempowerment—an experience with dimensions that, for her, were physical, psychological, even subconscious: “I felt like I was going to throw up; I had nightmares for a long time—I felt helpless.”

Power dynamics

The power dynamics theme was evident in descriptions of power struggles between parties involved in decision making about patient care. The power dynamics theme could involve family members, hospital administration, physicians, other nurses, and patients themselves. The theme arose in several stories about situations in which physicians chastised or ignored nurses when they conveyed patient wishes. Moral distress arose when physicians exerted power by declining to act or communicate about issues nurses judged important. Nurses described moral distress arising from power dynamics that involved family members, too. One nurse recounted the moral distress she experienced when a family that was demonstrably unable to provide care for their elderly parent refused to allow the patient to be moved to an assisted care environment. In instances in which power dynamics was a theme, nurses described how others used their structural or situational power to impose decisions that nurses found—and often argued—were not in the best interests of patients.

Lack of resolution

In the stories that exemplified this theme, nurses described spending a lot of time and energy trying to assert moral agency in situations that seemed to go on and on and over which the nurse ultimately had little power. This theme was captured by one nurse's frustrated recollection of time spent trying to change a patient's code. The goal was accomplished finally but only “after three to four months of ethics and multiple meetings with daughter and [hospital] administration.” Other examples involved “back and forth” between various parties, such as family members who changed their parent's code status several times—once during a code—leading to the patient's prolonged suffering. In another example, a nurse described repeated instances in which an older adult patient with fluctuating mental status appeared lucid and refused nursing care, followed by the family insisting that it be resumed. In stories in which lack of resolution was a theme, nurses described moral distress as disempowerment that arose specifically around the duration of unnecessary suffering and the nurses' extended struggles to resolve a morally distressing situation.

Structural analysis

Analysis of the structural composition of the moral distress stories yielded 2 findings (Table 3). First, we found a repeating pattern of complicating action with an absence of resolution in the structure of several stories, which was suggestive of the difficulty nurses reported in moving past conflict to reach resolution in morally distressing situations. Second, some of the stories demonstrated a lack or displacement of the coda—the moment, usually at the end of an account, when the storyteller pulls narration back into the present. In those cases, instead of bringing the narration full circle into the narrating moment, storytellers tended to cycle back to evaluation, as if trying to analyze their way to closure. These storytellers may have found it challenging to bring their stories to the present because the endings were not part of the present as they wanted it to be.

Table 3. - Structural Coding Grid for Moral Distress Storiesa
A B C D E F G H I J K L M Line in Story
AB AB OR AB AB AB AB OR AB AB AB AB AB 1
OR OR CA AB AB OR AB AB OR OR OR OR OR 2
OR OR EV OR OR CA CA CA OR OR OR OR OR 3
CA CA CA CA OR CA CA EV CA CA OR CA CA 4
CA EV CA EV CA OR EV CA EV OR CA EV EV 5
CA EV CA CA CA EV EV CA OR EV EV EV EV 6
EV Coda EV CA CA CA CA OR CA EV EV CA EV 7
EV RE EV CA CA EV CA OR CA Coda CA CA 8
RE Coda Coda OR CA RE RE OR EV EV CA 9
RE EV Cod EV CA Coda EV Coda Coda 10
RE CA RE RE EV EV Coda 11
OR CA EV EV 13
CA EV Coda 13
EV Coda 14
EV Coda 15
EV 16
Coda 17
Abbreviations: AB, abstract; CA, critical incident; Coda, end the narrative; EV, evaluation; OR, orientation; RE, resolution.
aLetters A to M indicate participant code.

Quantitative results

We hypothesized that an intervention based on Freire's problem-posing framework would result in lower moral distress. Results from the MDS-R partially met this expectation (Table 1). Nurses scored significantly lower means on overall moral distress (P = .006) and frequency (P = .034) following the intervention. Against our expectations, however, participants scored significantly higher on the MDS-R intensity subscale (P = .001). Also contrary to our hypothesis, there were no significant differences in Wilcoxon signed rank results for perceived personal (PES) (P = .07) or group empowerment (CWEQ-11) (P = .06) scores. Only 1 subscale in the surveys showed significant difference in means pre/postintervention. That was the subscale of meaning on the PES, a measure of a person's own valuation of the importance of the work he or she does, which increased (P = .046).

Convergence and divergence of qualitative and quantitative results

We found overall congruence between the general tendency of themes from the participants' moral distress stories and the results on the 3 scales (Table 4).1,2 The PES and CWEQ-II scores at baseline and at the end of intervention largely indicated that nurses felt disempowered both personally and collectively. That perceived lack of personal power and structural impact was codified extensively in the moral distress stories, where the narratives gave form and nuance to the survey results.

Table 4. - Convergence and Divergence in Qualitative and Quantitative Data
Aim Selected Qualitative Data Quantitative Data
Converging data
Feasibility and acceptability “I think you did a good job of getting all of the people caught up, [I mean] the ones that weren't there.” 100% of the sample recruited.
Zero percent lost to attrition.
No correlation between the number of sessions attended (2 vs 3) and any other variable including the MDS-R, PES, or CWEQ-II scores.
Address sources of moral distress “Patient in hospital for multiple weeks and not really doing anything to improve quality of life.”
“She [the patient] just had a very poor quality of life.”
“[The family] continued life prolonging treatments, multiple cardiac arrests, and continuous renal hemodialysis therapy.”
“I was told that the patient was admitted with respiratory distress and that the ED attempted to increase the size of the patient's tracheostomy [...].
The next morning the patient's tracheostomy became dislodged and the patient arrested.”
“When the patient was off the floor for a test, she [patient's girlfriend] confided in me that he [the patient] could be verbally and physically abusive towards her. [...] I came back the next day and was told by a co-worker in the clean utility room that he [the boyfriend] had murdered her.”
MDS-R Q3 “Continuing life support ... insistence of the family”: Frequently/very frequently (77%); very much/great intensity (100%).
MDS-R Q4 “Initiating life extending treatments ... prolong death”: Frequently/very frequently (69%); very much/great intensity (84%).
MDS-R Q6 “Carry out MD orders ... unnecessary tests and treatments”: Frequently/very frequently (46.2); very much/great intensity (69.2%).
MDS-R Q7 “Participate in care of ventilator ... no one will withdraw”: Frequently/very frequently (69.3%); very much/great intensity (92.3.%).
MDS-R Q16 “Follow family wishes ... for fear of lawsuit”: Frequently/very frequently occur (38.5%); very much/great extent (92.4%).
Identify personal empowerment “I feel like I have personal power but not a powerful position as far as making strategic decision.”
“I think that I have some personal power—so I perceive that I have some power but from the organization—not so much.”
“I have a voice, but I don't have power. They can hear me, but people don't listen.”
“There is a hierarchy, but the issue becomes when it is unsafe for patient care. I will go toe-to-toe very respectfully. But, if I don't feel comfortable with what's going on, I keep climbing that hierarchy until I get what I want.”
“I would say we do have perceived power, but not real power [...] when it comes down to it we're not really heard.”
“Sometimes, I feel like I have power and other times–no–I want to get things fixed but I just can't.”
PES “Impact at work”: positive (7.7%).
PES “Control at work”: positive (7.7%).
PES “Confidence in their ability to do their job”: positive (92.3%).
PES “Importance of work”: positive (84.7%).
PES “Autonomy to do the job”: positive (54%).
PES “Opportunities for independence and freedom”: positive (38%).
Identify structural power at work “Hospitals are so pro-nurse on the outside, but you don't really feel that. I think the projected image that we love our nurses and then once you get in, the question is-do you though?”
“Power in the organization? Yeah, but it's a very superficial thing. I think they are sometimes condescending to think that this is what's going to make people happy and it's not, and it's not fixing the real issue.”
“I really don't think I have power over anything, because I always have to ask permission to do anything to help the patient.”
“It's that dichotomy where you have so much responsibility, but you also are looked on as something like, you know, not, not important or not, maybe not as professionals.”
CWEQ-II INFO 1 “Knowledge state hospital,” positive (7.7%).
CWEQ-II INFO 3 “Knowledge goals of top management,” positive (7.0%).
CWEQ-II SUPPORT 1 “Access supportive advice from leadership,” positive (15.4%).
CWEQ-II SUPPORT 2 “Access to advice for improvements,” positive (7.7%).
CWEQ-II INFORMAL POWER 2 “Visibility in the organization,” positive (0%).
CWEQ-II GLOBAL 2 “Overall empowerment for work,” positive (31%).
Impact of intervention on moral distress levels “I felt like maybe I wasn't a strong enough person to handle the job or those kinds of feelings. And [now] you realize that's not necessarily the case.”
“Knowing that other people are going through it as well really makes it less stressful.”
“That what I am experiencing is moral distress—just understanding that helps a lot.”
“I don't know but since I have had this information, my bad dreams have gone away.”
MDS-R total mean and frequency mean scores significantly lower postintervention.
Diverging data
Impact of intervention on empowerment “I am more powerful than I gave myself credit for.”
“I learned to be more confident and speaking up for myself and other colleagues, if I'm being mistreated or if they're being mistreated.”
“That you know as a nurse there are things we experience that no other profession experiences and it's important for us to stick together, cause a lot of times [...] we're against each other and that's not the way to be.”
“I've gone to other seminars on moral distress and compassion fatigue, but this one taught us to apply system-wide plans to help things get better.”
“Being able to have the tools to use and look at the situation differently.”
No significant increase in either the mean PES or CWEQ-II
Abbreviations: CWEQ-II, Conditions of Work Effectiveness Questionnaire—II; MDS-R, Moral Distress Scale— Revised; PES, Psychological Empowerment Scale.

In a similar but more complex way, the qualitative findings converged with results from the moral distress scale. The MDS-R scores indicated that nurses experienced a lower frequency but a higher intensity of moral distress following the intervention. Although not what we expected initially, after further reflection, we understood these results to be in keeping with the transformative, coming-to-consciousness goal of the Freirean pedagogy, that is, a sensitizing process likely to lead to intensified feelings. In the moral distress stories, the postintervention interviews, and the MDS-R intensity scale, nurses exhibited their awareness of moral distress and readiness to acknowledge its legitimacy. As one nurse explained, “So I just opened my eyes to what it actually is. I thought ‘Am I feeling depressed? Am I doing something wrong?’ And [I'm] realizing, no, it's actually real and it's out there.”

Divergence in the qualitative and quantitative findings was also observed. The null effect of the intervention on participants' perceived feelings of empowerment as measured in the PES and CWEQ-II did not align with responses in the postintervention interviews (Table 4). Instead, in the interviews, most of the nurses expressed outright their growing sense of empowerment: “I'd say that I am more powerful than I gave myself credit for,” in the words of one, and from another: “I learned to be more confident and speak up for myself and other colleagues if I'm being mistreated or if they're being mistreated.” The moral distress stories codified the oppression of the nurses. The decodification of their experiences—a result of writing out and then discussing the stories with others who had their own similar accounts to share—seemed to be on display in the postintervention interviews. There, in contrast to the surveys, nurses bore witness to the transformative effects of the problem-posing approach, its capacity to initiate a process of emancipation by fostering a shared recognition of latent power and by offering tools to accomplish change.6,12

DISCUSSION

Thematic analysis of the moral distress stories in this study revealed that nurses recognized a range of sources for their moral distress. Other researchers have similarly documented sources of moral distress in nurses' perceptions of futility related to patient care and unnecessary or unwanted prolongation of life2,7; unwarranted aggressive treatment28,29; and unsafe care.7,30 We also found, in keeping with research conducted over the past 30 years, that moral distress is often a product of power dynamics between nurses, patients, families, administrators, and physicians.2,7 Too often, results of those power struggles take the form of anger,7,31 unrealistic expectations,32 and bullying7 directed at nurses. Our results confirmed findings by Varcoe et al,31 who discovered that nurses were especially affected by situations in which their efforts to resolve a morally distressing situation garnered no result. We, too, found among nurses' accounts a repeated theme of failure of resolution, which nurses both codified in the attention to time and duration in the content of their moral distress stories and rendered structurally through lack of narrative closure and cyclical return to conflict.

Moral distress frequency and overall scores decreased significantly following the conscientization intervention, while counter to our expectations moral distress intensity scores increased significantly. This result was similar to what Leggett et al33 found in their mixed-methods pilot of an intervention to educate and increase self-efficacy in nurses who worked in a burn unit. As in our study, nurses in the research by Leggett et al may have felt more sensitized to distress after an intense examination of it. Our other unexpected finding from the surveys (though not the interviews) was that nurses' feelings of personal and group empowerment did not change following the intervention. Leggett et al similarly saw no change in self-efficacy scores postintervention. Self-efficacy is generally an individual measure (in contrast to group empowerment), but the 2 are comparable in that both feature a perceived capacity to effect change. Contrary to the findings by Leggett et al and to the PES and CWEQ-II results in this study, nurses in our postintervention interviews expressed a strong sense of the empowering results of working as a group for small system changes.

One empowerment measure that did show significant increase pre- to postintervention was the PES subdimension measure of meaning. Meaning is the perceived value of one's work in relation to one's own ideals and standards.18 Malloy et al34 have documented that nurses experience their work as meaningful in part through identification with their role and connectedness to others. The increased meaning score in our study may reflect participants' sharpened identification with their nursing perspective and the potential impact of their nursing role. This would have been reinforced in the intervention through the collective decodifying of moral distress stories. An increased ability to join with others in affirming correspondences between work and values likely acts as an antidote to oppression and particularly to its insidious tendency to lead to a group's assimilation and internalization of that oppression. Meaning for the nurses in this study developed as part of the conscientization process, prefiguring its more outward manifestations in action. As one nurse remarked about the links between power and action, “If you don't perceive that you have any power, when you do have the situation where do you have real power, I think you're not going to take that [power].”

Much of what we found in the moral distress narratives and surveys has precedent in the literature. Unlike other work, however, ours is the first published interventional study we could find that addresses nurses' moral distress as an instance of group oppression and one whose source and resolution may both lie in understanding and working collectively to change the dynamics of power in the health care workplace. We know of no other application of Freire's problem-posing framework and pedagogy as a means to help nurses recognize and empower one another to remove the causes of moral distress.

Limitations

Despite its strengths—including uniqueness of approach and the triangulation of data sources—several limitations affected the study. First, this was a pilot with a small sample size and thus limited power to detect intervention effects as measured by the surveys. Second, the homogeneous makeup of the sample potentially diminished the external validity of the study, especially since a sample with more diverse racial and gender characteristics may well have displayed different experiences of moral distress and propensities for empowerment (though it also bears noting that a more gender and race diverse group might have reproduced intragroup hierarchies that complicate the foundational assumptions of shared oppression). Third, initial coding of the qualitative data was performed mainly by the first author with contributions to thematic interpretations by the second and review by a group of advisors. Although discussed by the team, the themes were based on preliminary coding of the data by the first author. This singleness of perspective may decrease the trustworthiness of the interpretation.26 Finally, conscientization is a continual and cyclical process in which members of a group learn and relearn about themselves and their relationship to the world.6 To fully realize the effects of conscientization, an intervention would need to be a sustained process extending well beyond 3 weeks.

CONCLUSION

The implications of this study merit close attention. We showed that a problem-posing educational intervention based on a Freirean framework of conscientization was feasible and acceptable to nurses. Participants gained knowledge about the role that oppression played in their experiences of moral distress and how and why they had been suffering alone and mostly in silence. Nurses discovered ways to work together to disrupt oppression, set goals, and develop action projects based on weighing what they thought would work and not work. The results embodied the beginning of what Freire (1995) called conscientization or “taking action against the oppressive elements of their reality.”6(p17) The study showed that a process of critical reflection, critical motivation, and critical action could help nurses develop tools not only to prevent moral distress from happening to them in the future but also to teach and mentor others. Results from this study indicate that a more robust trial with a larger, more diverse sample and a longer implementation period is merited. Through successful conscientization, nurses can empower themselves to join forces in raising their moral voices in situations in which they might formerly have felt alone and silenced.

REFERENCES

1. de Veer A, Francke A, Struijs A, Willems D. Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud. 2013;50(1):100–108. doi:10.1016/j.ijnurstu.2012.08.017.
2. Oh Y, Gastmans C. Moral distress experienced by nurses. Nurs Ethics. 2015;22(1):15–31. doi:10.1177/0969733013502803.
3. Young A, Froggatt K, Brearly SG. “Powerlessness” or “doing the right thing”: moral distress among nursing home staff caring for residents at the end of life: an interpretive descriptive study. Palliat Med. 2017;31(9):853–860. doi:10.1177/0269216316682894.
4. Roberts SJ. Oppressed group behavior: implications for nursing. Adv Nurs Sci. 1983;5(4):21–30. doi:10.1097/00012272-198307000-00006.
5. Young IM. Five Faces of Oppression: Justice and the Politics of Difference. Princeton, NJ: Princeton University Press; 1990
6. Freire P. Pedagogy of the Oppressed. New York, NY: The Continuum International Publishers; 1995.
7. Huffman D, Rittenmeyer L. How professional nurses working in hospital environments experience moral distress: a systematic review. Crit Care Nurs Clin North Am. 2012;24(1):91–100. doi:10.1016/j.ccell.2012.01.004.
8. Dubrosky R. Iris Young's five faces of oppression applied to nursing. Nurs Forum. 2013;48(3):205–210. doi:10.1111/nuf.12027.
9. Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace bullying in nursing: towards a more critical organisational perspective. Nurs Inq. 2006;13(2):118–126. doi:10.1111/j.1440-1800.2006.00314.x.
10. Clark C, Olender L, Kenski D, Cardoni C. Exploring and addressing faculty-to-faculty incivility: a national perspective and literature review. J Nurs Ed. 2013;52(4):211–218. doi:10.3928/01484834-20130319-01.
11. Rodwell J, Demir D. Oppression and exposure as differentiating predictors of types of workplace violence for nurses. J Clin Nurs. 2012;21(15-16):2296–2305. doi:10.1111/j.1365-2702.2012.04192.x.
12. Wallerstein N, Auerbach E. In: Le Rougetel A, Isserlis J, eds. Problem Posing at Work: Popular Educators' Guide. Edmonton, AB, Canada: Grass Roots Press; 2004.
13. Rugut EJ, Osman AA. Reflection on Paulo Freire and classroom relevance. Am Int J Soc Sci. 2013;2(2):23–28.
14. Freire Institute. Paulo Freire Workshop: The Learning Process. Burnley, England: Freire Institute; 2016.
15. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. Thousand Oaks, CA: SAGE Publications; 2014.
16. Watts R, Diemer M, Voight A. Critical consciousness: current status and future directions. New Dir Child Adolesc Dev. 2011;2011(134):43–57. doi:10.1002/cd.310.
17. Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Prim Res. 2012;3(2):1–9. doi:10.1080/21507716.2011.652337.
18. Spreitzer GM. Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad Manag J. 1995;38(5):1442–1462. doi:10.22307/25686522.
19. Spreitzer GM, Quinn RE. A Company of Leaders. Five Disciplines for Unleashing the Power Your Workforce. San Francisco, CA: Jossey-Bass; 2001.
20. Laschinger HKS, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings. J Nurs Adm. 2001;31(5):260–272. https://doi.org/10.1097/00005110-200105000-00006
21. Faulkner J, Laschinger H. The effects of structural and psychological empowerment on perceived respect in acute care nurses. J Nurs Manag. 2008;16(2):214–221. doi:10.1111/j.1365-2834.2007.00781.x.
22. Saldaña J. First cycle coding materials. The Coding Manual for Qualitative Researchers. 2nd ed. Thousand Oak, CA: SAGE Publications Inc; 2013:58–187.
23. Labov W. Speech actions and reactions in personal narrative. In: Tanned D, ed. Essays on the Verbal and Visual Arts. Seattle, WA: University of Washington Press; 1972:112–144.
24. Mishler EG. Models of narrative analysis: a typology. J Narrative Life Hist. 1995;5(2):87–123.
25. Riessman CF. Narrative Methods for the Human Sciences. Thousand Oak, CA: SAGE Publications; 2008.
26. Lincoln Y, Guba E. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir Program Eval. 1986;30:73–84. doi:10.1002/ev.1427.
27. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 2nd ed. Thousand Oaks, CA: SAGE Publications; 2011.
28. Houston S, Casanova MA, Leveille M, et al. The intensity and frequency of moral distress among different health care disciplines. J Clin Ethics. 2013;24(2):98–112.
29. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among health care professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117–125. doi:10.1111/jnu.12115.
30. Wilson M, Goettemoeller D, Bevan N, McCord J. Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses. J Clin Nur. 2013;22(9-10):1455–1466. doi:10.1111/jocn.12128.
31. Varcoe C, Pauly B, Storch J, Newton L, Makaroff K. Nurses' perceptions of and responses to morally distressing situations. Nurs Ethics. 2012;19(4):488–500. doi:10.1177/0969733011436025.
32. Ganz FD, Raanan O, Khalalila R, et al. Moral distress and structural empowerment among a national sample of Israeli intensive care nurses. J Adv Nurs. 2012;69(2):415–424. doi:10.1111/j.1365-2648.2012.06020.
33. Leggett J, Wasson K, Sinacore J, Gamelli R. A pilot study examining moral distress in nurses working in one United States burn center. J Burn Care Res. 2013;34(5):521–528. doi:10.1097/bcr.0b013e31828c7397.
34. Malloy DC, Fahey-McCarthy E, Murakami M, et al. Finding meaning in the work of nursing: an international study. Online J Issues Nurs. 2015;20(3):7. https://www.ncbi.nlm.nih.gov/pubmed/26882516. November 21, 2019.
Keywords:

action research; critical care nursing; empowerment; moral distress; nurse's role/psychology

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