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Running head: MORAL DISTRESS AND PALLIATIVE CARE 1

Nurses’ Moral Distress and the Role of Palliative Care: A Systematic Review

MORAL DISTRESS AND PALLIATIVE CARE 2

Abstract

Moral distress has been a topic in nursing literature for over 20 years. Researchers have

documented its conceptual meaning, presentation, and impact through qualitative and

quantitative methods as well as reviews. Recently, efforts have been made to determine the

effectiveness of various interventions on moral distress. One of these is these is the role of

palliative and end of life care education. The purpose of this review was to describe how

palliative and end of life care impacts moral distress scores in nursing professionals. The

research design was a systematic review which produced three articles published between 1987

and 2018 which matched the search criteria. Through the PRISMA reporting guidelines, the

findings are presented in a narrative synthesis. From the analysis, it emerged that the

heterogeneity among variables, measurement and definition of moral distress, and selection bias

and confounding variables impacted the interpretation of the included studies. Few studies

examine how palliative care and end of life care education impacted nursing moral distress.

Furthermore, determining conceptual validity of the measurements used is encouraged.

Nurses’ Moral Distress and the Role of Palliative Care: A Systematic Review


Moral distress is an important issue as it pertains to healthcare professionals due to its

negative impact on the professional’s mental and emotional wellbeing, turnover, and patient care

(Hamric, 2012). Although moral distress can occur in personal and professional settings, the

focus on nurses’ moral distress emerged with the rise of feminist ethics in the 1970s (Jameton,

2013). At that time, most medical ethical dilemmas focused on the role of the male physician

which reflected hospital paternal bureaucratic structures. Philosophers sought to support the

female dominated nursing profession and encourage their confidence and voice. Since then,

moral distress research has expanded and is encouraged in the fields of social work, medical

students, education, and others (Bradbury-Jones, Ives, Irvine, & Morley, 2017). Although the

causes of nursing moral distress are well understood, interventional outcomes remain under-

researched (Hamric, 2012).

Moral distress is a unique concept concerned with the psychological reaction to a moral

event (Morley et al., 2017). With over 20 definitions of what constitutes moral distress, there is

no consensus on how moral distress is defined. Jameton (1984) introduced moral distress as the

experience of negative feelings when a course of action is blocked by institution constraints.

Wilkinson, Corley, Hanna, and others have elaborated and supplemented their own notions of

what constitutes moral distress (Mareš, 2016; Morley et al., 2017). However, for the purposes of

this research, moral distress will be defined consistent with Jameton’s definition with Corley

(2002) and Borchers, Epstein, and Hamric (2012) interpretation: the response a nurse gives to a

moral situation where the nurse feels a sense of responsibility and their core beliefs or values

have been violated due to internal and/or external constraints. Internal constraints can be

perceived powerlessness or incompetency, whereas external constraints can be inflicted by the


institution or culture, such as lack of administrative support or having adequate time to complete

tasks and meet patient needs (Hamric, Davis, & Childress, 2006).

A variety of measurement tools have been developed in part due to the lack of

conceptualization consensus (Borchers, Epstein, & Hamric, 2012). Recent comprehensive and

systematic reviews have reported root causes and consequences of moral distress, but

methodologies included a variety of instruments that capture the phenomenon (Lamiani, Borghi,

& Argentero, 2017; McAndrew, Leske, & Schroeter, 2016; Wocial & Weaver, 2013; Younjae &

Gastmans, 2013). One of the earliest measurements of responses to moral dilemmas was

administered by Crisham (1981) to gauge nurses’ responses to ethical dilemmas. The Nursing

Dilemma Test (NDT) had poor reliability and lead to the creation of the Moral Distress Scale

(MDS) in 2001 (Corley, Elswick, Gorman, & Clor, 2001; Corley & Selig, 1994). In 2005, Corley

and colleagues revised their original scale to include six additional items from new literature and

dichotomized options to include frequency and intensity (MDS-A). Hamric, Borchers, and

Epstein (2012) conducted another revision to the scale (MDS-R) and expanded it to include other

health care professionals. The new scale is 21 items with 5-point Likert scale to reflect frequency

and intensity (α= .88). Each of the revisions of the MDS is based on research findings to reflect

the most current causes associated with moral distress. In 2013, Wocial and Weaver developed

the moral distress thermometer. This tool allows for moral distress to be measured in its current

state (rather than cumulative) with an eleven-point analogue scale. Other studies have used

unique questionnaires and some unidimensional measurements (Rathert, May, & Chung, 2016).

Through qualitative and quantitative measures, existing literature demonstrates

contributing sources of moral distress from patient and family, unit and team, and system and

organizational levels (Hamric, Whitehead, Prompahakul, & Esptein, 2018). Organizational


factors such as lack of support, respect, ethical debate, collaboration, access to resources and

adequate staffing (Hamric et al., 2012; Lamiani et al., 2017; Nathaniel, 2006). Although these

issues can be problematic for all healthcare professionals, these constraints create difficult

working environments for nurses. Nurses are often seen as advocates for patients but have a

limited role in controlling the treatment plan. Whether a nurse receives adequate support from

his or her administration can be crucial. In fact, studies have examined the relationship between

ethical workplaces and moral distress and consistently find a negatively correlated relationship

(Pauly, Varcoe, Storch, & Newton, 2009).

Whether a situation is considered morally distressing is a matter of individual nurse

perception. Nurses who feel they are forced to make decisions which conflict with professional

and/or institutional norms contributes to moral distress (Nathaniel, 2006). The constraints may be

real, but whether a nurse considers something to be morally distressing depends on the nurse.

The perception of powerlessness and ethical issues can amplify moral distress which reflects the

web of interactions among lack of organizational support, ethical environments, and individual

nurse contributions (Huffman & Rittenmeyer, 2009; Rathert et al., 2016).

Nurses report infrequent situations of moral distress, but when moral distress occurs,

nurses report intense levels (McAndrew et al., 2016; Younjae & Gastmans, 2013). Situations

where patient autonomy is disregarded, perceived pain and suffering, futile care, and lack of

informed consent and truth telling (honesty with patients about their medical condition) can be

sources of moral distress (Gillon, 1985; Hamric et al., 2012; Huffman & Rittenmeyer, 2009).

If left unaddressed, moral distress can create consequences for the nurses emotional and

psychological wellbeing, the institution, and patient-care. As a result of moral distress, nurses

have reported negative psychological, biological, and stress reactions (Huffman & Rittenmeyer,


2009). Over time, unresolved moral distress builds up and this moral residue contributes to the

intensifying of situations which feel familiar (Epstein & Hamric, 2009). In the presence of

internal constraints, often nurses will blame themselves but resort to blaming others when

dealing with external constraints (Dudzinski, 2016). These realities contribute to burnout, impair

work satisfaction, and turnover (Hamric et al., 2006; Rosenstein, 2002; Whitehead et al., 2015).

Leske, McAndrew, & Schroeter (2016) identified multiple studies which found moral distress

can contribute to nurses becoming desensitized, withdraw from patient care, and avoid patients

and families. This can have implications for the quality of care patients and families may receive.

A common source of moral distress is around perceived futile care and end of life care

(Hamric & Blackhall, 2007; Langley, Kisorio, & Schmollgruber, 2015; Whitehead et al., 2015).

End of life care education and access to palliative care consultation teams have been proposed as

an intervention to reduce distress around end of life care (Cavinder, 2014; Corley, 2002; Hamric,

2012; Lützén & Kvist, 2012). As a consultation service, palliative care teams aim to relieve

patient suffering through aggressive biopsychosocial symptom management and aid with

complex medical decision making (Morrison & Meier, 2004; Weissman & Meier, 2011).

Through this service, consultation for the primary service is provided through guidance and

education. As research emerges to address moral distress in nurses, clarifying the role of

palliative and end of life education, training, or consultation services would be beneficial to

guide intervention development. This systematic review will seek to identify methods of

palliative and end of life delivery and determine its impact on moral distress in registered nurses

involved in direct patient care. Study objectives will be to 1) identify the study’s

conceptualization of moral distress 2) Identify the mode of delivery and content of palliative or


end of life intervention and 3) To assess the impact of palliative and end of life training/

education/ consultation on levels of moral distress.

Methods

Search Strategy, Data Sources, and Study Selection

A systematic electronic search was conducted in EBSCOhost, Academic Search

Complete, Medline, Social Work Abstracts, Open dissertations, Psychology and Behavioral

Sciences Collection, PsychInfo, CINAHL, Web of Science, and Google Scholar databases as

well as ancestral searches in December 2018. The screening of titles and abstracts was done by

this author. Figure 1 shows the detailed search strategy including search terms, yielded hits, and

titles kept for abstract review. Moral distress and palliative/end of life care was searched within

PROSPERO, an international database of systematic reviews in health and social care and

welfare, and no existing systematic reviews or protocols were found. The study included all

quantitative studies since 1987 with quasi-experimental and observational studies published in

English. Qualitative studies including case reports, discussions, editorials, or reviews were not

included. The population under consideration included registered nurses in any setting (ICU,

academic hospital, outpatient clinic, etc) providing care for adults or pediatric patients. Student

nurses were excluded. The main-focus of the studies had to be the use of palliative or end of life

care training, education, or consultation and its relationship with moral distress. All conceptual

definitions of moral distress as well as moral residue and moral stress, however, other concepts

closely related such as moral voice, agency, and emotional distress were excluded. Published

conference abstracts with no full article were also excluded. Identified titles and abstracts were

screened against the inclusion criteria to find potentially relevant papers. The search strategy was

adapted during the search process to account for vague titles.


Data Extraction and Quality Assessment Tools

Data was collected from the included articles and assessed for study quality by two

independent reviewers. Methodological quality and risk of bias was assessed using the National

Institute of Health’s (NIH) Quality Assessment Tool for Observational Cohort and Cross-

sectional Studies (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools). The

tool was selected based on the type of studies and methodologies used in the included studies for

review. The NIH Quality Assessment tool consists of 14 criteria and a three-level rating system

(good, fair, and poor). The tool also provides additional pages for criteria guidance to appraise

included studies. Not all aspects of the studies were applicable to the NIH assessment tool, so

The Cochrane Risk of bias tool (Higgins, Altman, & Sterne, 2011) and synthesis robustness was

also chosen to assess study quality.


Figure 1: Search Strategy Including Terms, Hits, and Titles Kept


Data Synthesis and Analysis

This study incorporated the Preferred Reporting Items for Systematic Reviews and Meta-

Analysis (PRISMA) checklist for reporting systematic reviews to reflect best practice and

transparency in reporting systematic reviews (Liberati et al., 2010). Because of heterogeneity in

the methodologies, interventions, and outcomes of the included studies, pooling of quantitative

data to perform a meta-analysis was not possible and therefore a narrative synthesis was

undertaken.

The Ryan and the Cochrane Consumers and Communication Review Group (CC & CRG)

(2013) was used to guide the narrative synthesis. A narrative synthesis is encouraged to

investigate similarities, differences, and patterns among study findings. It proposes four

interactive elements: 1) theory development 2) preliminary synthesis of findings 3) exploration

of relationships between studies and 4) assessment of the robustness of the synthesis. The role of

palliative and end of life training theorizing its role in the context of nurse moral distress was has

been explored, the remaining three elements will be discussed.

Results (preliminary synthesis)

Of the 11,409 potentially relevant publications, two published articles and one

dissertation met all the inclusion criteria. A flowchart illustrating the process of study selection is

shown in Figure 2. Characteristics of the included studies are summarized in Table 1, 2 and 3.

The included dissertation by Wolcott and colleagues (2016) discussed three separate studies from

the same data source. One published article summarized two of the three studies within the

dissertation and was excluded (Altaker, Howie-Esquivel, & Cataldo, 2018). There was only one

study with a quasi-experimental design whereas the other two studies were non-experimental


cross-sectional designs. All three studies used a version of the Moral Distress Scale with a

variety of other measures of palliative or end-of-life care education, training, and consultation.

Quality Assessment of the Included Studies

Each study included in the review was independently reviewed by an additional reviewer,

initial JO. This author and JO had 100% interrater agreement regarding all three studies.

The likelihood of selection bias was moderate in the trials included in the study. Blinding of

outcome assessors and participants was not possible. Two studies were conducted via e-mailed

newsletter and/or social media and the third was in a single center. Measures used were reliable

and valid. Other than the dissertation, statistical analysis reporting was limited and non-

transparent contributing to result bias and unclear interpretations of the relationship between

independent and dependent variables.

Bosshardt and colleauges (2018) was the only study to measure moral distress across

time but was unable to control for potential confounding variables. Response rates were low or

not reported and confounding variables were a limitation in all three studies. None of the studies

could offer causality or generalizability.


Figure 2 Flow diagram of the study selection procedure


Characteristics and Outcomes of Included Studies

Only one study explored the impact of a palliative consultation intervention by measuring

levels of moral distress with the MDS-R with pre and post intervention (Bosshardt, 2018). They

also used a mixed-methods design, but the qualitative analysis was not included in the

assessment or data analysis for the purposes of this review. Authors hypothesized a policy

change of allowing nurses to independently consult palliative care without a physician’s order

would contribute to lower levels of moral distress. Although the intervention involved a

palliative consultation service, the authors suggested nurse empowerment would contribute to

distress reduction. They found there were no changes in average MDS scores between rounds but

there was a significant change in the frequency of reported events for 1) provision of less-than

optimal care (14.4% compared with 24.1%, p=.0378), 2) continuation of care for a hopelessly ill

patient (34.6% compared with 23.1%, p=.0397), caring for patients they did not feel qualified to

care for (5.3% compared with 14.8%, p= .0055), and working with other health care providers

were not competent to care for the patient (13.9% compared with 26.9%, p= .0059). The nature

of the methodology doesn’t lend itself to draw conclusions about whether it was the policy

change, palliative care consultation, or the campus wide end of life care education efforts that

took place during that time that impacted findings.

The other two studies utilized a cross-sectional e-mail- based survey to assess levels of

moral distress within the same nurse network, the AACN (Browning, 2013; Wolcott, 2016).

Browning (2013) focused on the relationship between psychological empowerment, moral

distress, participation in end-of-life care conferences, and end-of-life education through a nursing

curriculum, End-of-Life Nursing Education Consortium (ELNEC), along with other

demographic variables. Wolcott (2016) used a slightly different approach also measuring


psychological empowerment and moral distress, but incorporated hospital ethical climate,

perceptions of palliative care in the ICU, methods of inclusion, and level of palliative care

education held by nurse participants.

Browning (2013) analyzed results by comparing total MDS, frequency and intensity

MDS scores, as well as subscales of the MDS (individual responsibility, not in patient’s best

interest, and deception). Through correlational analysis Browning (n=277) determined weak but

significant positive associations with higher moral distress frequency and intensity on the item

“not in patient’s best interest” and age of the nurse (r=.0179, p=.01) and ELNEC training

(r=0.185, p= .008). Authors also reported weak, significant positive correlations 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).” (p. 148). Nurses who participated in end- of- life

care conferences had a weakly associated reduction in moral distress scores related to the

subscale “deception” (r=-0.191, p=.007).

The regression model within Browning’s (2013) study included total psychological

empowerment scores (PEI) and demographic variables. No table was provided for further

interpretation, but authors reported 28.9% of moral distress frequency variance was explained by

the model (F (2,171) = 7.801, p < .01). Two predictors, ELNEC training (β=-.215, p<.01) and

PEI total scores (β=.222, p<.01) explained 8.40% of moral distress frequency variance. It is of

note, within this study, only 16 respondents had ELNEC training.

Wolcott (2016) in her dissertation used correlations, regression, analysis of variance, and

T-tests to explore the relationship among access to a palliative care consultation team, palliative

education, psychological empowerment, ethical climate, and moral distress using MDS scale

revised (MDS-R). Among participants (n=235), 73% (n=171) reported having access to a full


palliative care team defined as specialist palliative care physicians, nurses, social workers, and

spiritual care practitioners. Authors determined access to a palliative care team did not influence

the association between ethical climate and moral distress or empowerment and moral distress.

They did determine significant differences of total MDS-R scores (n= 238) between nurses who

had access to a palliative care team (M= 102.3, SD= 57.2) and nurses who did not (M= 79.8,

SD= 49.4).

Through multiple regression analysis (N= 218), authors explained 37.7% of the variance

within moral distress scores was explained by ethical climate, psychological empowerment,

access to full palliative care team, number of beds in unit, ethnicity, years of experience,

educational degree, and facility. Access to a full palliative care team was a significant contributor

(β= .152, F(1205)= 6.791, p =.01). Other factors which significantly contributed were ethical

climate (β= -.379, F(1205)= 39.589, p = .001), number of beds in unit (β= .229, F(1205)=

15.335, p<.001), African American nurses vs Caucasian, Asian, and “other” (β= -0.193,

F(1205)= 10.317, p= .002), and educational degree (F(3205)= 5.932, p= .001). Within

educational degree, associate’s vs diploma in nursing (β= .238, F=7.431, p= .007), BSN vs

diploma in nursing (β= .425, F=17.530, p <.001), and MSN and beyond vs diploma in nursing

(β= .258, F= 8.874, p=.003) were all significant.


Study design Measure Study setting

Number of participants

Intervention/ Variables

Analysis Outcome/ Dependent Variable(s)

- Quasi-experimental One Group Pretest-Posttest

- Web-based survey

Moral distress Survey Revised (MDS-R)

700- bed academic medical center

200 round 1 (10% response rate)100 round 2(5% response rate)

Policy change allowing RNs to consult palliative independently of physicians

Descriptive

Chi-square

- No MDS mean differences between rounds

- Higher distress around perceived coworkers’ competency and feeling qualified to care for patients after policy change

- Lower distress with continued care for a hopelessly ill patient after policy change

- Decreased frequency of perceived futile care being provided after policy change

Study design

Measures Study setting


Intervention/ Independent

Analysis Outcome/ Dependent

Table 1 Bosshardt, Coyne, Marsden, Su, & Melvin (2018). Palliative care consultation policy change and its effect on nurses’ moral distress in an academic medical center.


Variable(s) Variable(s)- Non-experimental Cross-sectional

- Web-based survey

MDS-R

Hospital Ethical Climate Survey (HECS)

Psychological Empowerment Instrument (PEI)

Questionnaire assessing perceptions of Palliative Care (PC) in ICU, methods of PC inclusion, and level of PC education

American Association of Critical-Care Nurses (AACN) email newsletters/ social media

238 nurses (no response rate reported)

- Access to specialist PC team

- PC education topics

Descriptive

Correlations Multiple Regression

ANOVA

T-tests

- 73% (n=173) of nurses claimed access to PC

- PC does not influence association between ethical climate and MD

- Higher MDS mean score associated with having access to PC team

- Higher MDS scores predicted by access to a full palliative care team as well as other factors

Study design

Measures Study setting


Intervention/ Independent Variable(s)

Analysis Outcome/ Dependent Variable(s)

Table 2 Wolcott. (2016). Moral distress of ICU nurses and palliative care in the ICU


Non-experimental cross sectional

Web- based survey

MDS

PEI

personalized demographic survey assessing End-of- Life Nursing Education Consortium (ELNEC) training, end-of-life education in last year, collaboration in end-of-life care conferences

AACN email newsletters

277 nurses (.35% response rate)

psychological empowerment

demographics from survey (includes ELNEC training, end -of-life care conferences, and end-of-life education)

descriptive

correlations

multiple regression

- 5.8% (n=16) participated in ELNEC

- 54.6% (n=151) had end-of-life care education

- Higher MDS frequency with ELNEC training

- Lower MDS frequency scores addressing impending death honestly with patient associated with participation in end-of-life care conferences

- Higher MDS scores within “not in patient’s best interest” subscale associated with ELNEC training

- Higher MDS scores related to perceived futile care associated with nurses advanced in age and who had ELNEC training

- Higher MDS frequency scores predicted by ELNEC training

Unique to this study was the examination of specific palliative care education topics in

moral distress among nurses. Wolcott (2016) identified five components of palliative education

Table 2 Browning. (2013). Moral distress and psychological empowerment in critical care nurses caring for adults at end of life.


as: pain management, symptom management (anxiety/ depression), goals of care conversations,

discussion of suffering, and code status. Significant differences were found for all topics except

code status. Nurses with education in pain management had total MDS score of 94.6 (sd= 57.6)

compared to nurses without education in pain management (72.8) (n=213, t(24.7)= -2.3, p=.03).

Nurses with education in anxiety and depression had MDS score of 91.3 (sd= 58.9) compared to

nurses without education who had a total score of 67.4 (n=183, t(111)= -3.4, p=.001). Nurses

with education around communication around prognosis had MDS score of 90.6 (sd= 59.7)

(n=169, t(157.4)= -3.0, p=.003) with a mean difference of -21.2 compared to nurses without

education. Nurses with education around GOC had MDS score of 90.2 (sd=59.0) (n=178,

t(129.4)= -3.8, p<.0001) with a mean difference of -26.6 compared to nurses without education.

Nurses with education around Suffering had MDS score of 90.9 (n=167, t(170.7)= -2.8, p=.005)

with a mean difference of -19.4 compared to nurses without education. Additionally, nurses who

had education had less total moral distress scores and distress intensity, but no changes in

frequency.

Discussion (exploring relationships)

This section attempts to discuss the studies according to their aims and objectives, then

identify “how the results of the studies might be affected by factors such as methodological

differences between studies, or variable characteristics of the populations studied” (Ryan &

Cochrane Consumers and Communication Review Group, 2013, p. 4). Within the three articles,

three distinctive strands emerged.

1. Heterogeneity among palliative and end-of-life variables

2. Measurement and definition of moral distress

3. Selection bias and confounding variables


Heterogeneity among variables

There were three ways palliative or end of life care was used as an intervention among the

included studies: access to palliative consultation teams, palliative or end-of-life care education,

and involvement in end-of-life care conferences. Bosshardt and colleagues (2018) aimed to

address whether nurses’ ability to consult palliative care teams independently of physicians

would promote empowerment and therefore decrease levels of moral distress. They discovered

no differences in total moral distress scores after the policy change. Authors theorized campus

wide end-of-life education may have played a role in selection bias and higher distress around

perceived coworker competency and nurses feeling qualified to care for patients. The frequency

of palliative consultation before and after policy change was not reported. It was unclear how

they measured “access” to consultation teams.

Wolcott also sought to establish a relationship between access to palliative care consultation

teams and determined access was associated with higher moral distress levels. A questionnaire

was used to determine access to palliative care through multiple questions and the questionnaire

was provided in the final report. The author also explored education topics and found over 20%

of nurses in the sample had no palliative care education. However, for those who had education

in pain and symptom management, goals of care, suffering, and prognosis had less moral

distress.

Browning (2013) was also interested in the role of education and studied the use of ELNEC

training, end-of-life focused continuing education, and participation in end-of-life care

conferences. Nurses who were older and had ELNEC training had more frequent distress around

following family or physician orders incongruent with their opinion and terminally ill patients


receiving unnecessary medical treatments. The frequency of distress with perceived deceptive

medical treatment was lessened for nurses who participated in end-of-life care conferences.

Measurement and Definition of Moral Distress

In 2012, Hamric addressed challenges and opportunities present in existing research on moral

distress. Two of her recommendations were for future research to have consistency in defining

moral distress and include the use of valid instruments. Included studies cited Jameton (1984) as

the first to introduce moral distress and discussed the impact of constraints. The study by

Bosshardt and colleagues (2018) was the only study to discuss other definitions of moral distress

citing Fourie (2017) and Sirilla (2014).

All included studies used a version of the Moral Distress Scale (MDS) as their measurement

tool. Browning (2013) used the original MDS developed by Corley, Elswick, Gorman & Clor

(2001) while Bosshardt and colleagues (2018) and Wolcott (2016) used MDS revised (MDS-R).

The MDS was developed based on existing research, interviews with staff nurses, consultation

with Jameton, and consensus from nursing PhDs. The MDS consists of 32 items and resulted in

three separate factors: responsibility (α= .97), not in patient’s best interest (α= .82), and

deception (α= .84). Hamric, Borchers, & Epstein (2012) conducted another revision to the scale

(MDS-R) and expanded it to include other health care professionals. The MDS-R is a 21- item

scale with 5-point Likert scales to reflect frequency and intensity (α= .88). Each of the revisions

of the MDS is revised to reflect recent literature.

Heterogeneity was also observed in measurement interpretation which contributed to

comparison challenges. For example, Bosshardt et al. (2018) organized the Likert frequency

scores of zero to four arbitrarily into “never” or “infrequently” (scores of zero, one, or two) and

“frequently” and “very frequently” (scores of three and four). Whereas, Wolcott (2016) offered


no classification but reported averages in relationship to their total possible scores (zero-336) and

frequency and intensity subscales (zero-84). Browning (2013) also subjectively classified scores

on the MDS Likert scores of one to seven by groupings of “low” (0-2.33), “moderate” (2.34-

4.66), and “high” (4.67-7).

Selection bias and confounding variables

All three studies included in the review were unable to control for participant selection

bias and confounding variables. Authors discussed selection bias within their limitations and

acknowledged nurses who are interested in palliative issues may be more willing to participate in

their study. Both Wolcott (2016) and Browning (2013) used multiple regression to control for

potential confounders. The value was the ability to see the contribution of the palliative or end of

life intervention in comparison to other variables. According to Corley, Hamric, and Hamric and

colleagues (as cited in Wolcott, 2016), there is “no single factor independent of environment is

consistently responsible for moral distress levels” (p. 81). Determining whether palliative or end

of life care contributes to the reduction of moral distress levels may require advanced analysis

such as structural equation modeling.

The t-test and chi-square analysis was most commonly used included studies to test for

differences between groups or variables. Although these tests allowed authors to argue there is a

difference, they do not allow the authors to determine why these differences exist. This put limits

on the results and ability to draw conclusions on the role of palliative or end of life interventions.

Future research could benefit from more rigorous methods to randomize participants or

statistically control for confounding variables.

Awareness and constraints


Although education has historically been proposed as an intervention to reduce moral

distress, authors theorized the increased awareness may become another internal constraint.

Corley’s (2002) conceptual framework on moral distress proposed palliative care may support

nurses’ moral courage enabling them to morally act and prevent moral distress (Bosshardt et al.,

2018).

The level of support palliative can offer may depend on its level of integration in the

hospital structure (Wolcott, 2016). Nurses’ attitudes, perceptions, and understanding of palliative

care may influence whether palliative is appropriate and helpful for the patient in that setting.

She went on to say palliative consultation services can “elevate expectations of care for dying

patients…but unless the palliative care team is active in the unit, these expectations may face

barriers” (p. 30). These barriers can create more constraints which would increase distress.

Education may not be enough to reduce these barriers and pose threat of becoming an additional

barrier itself.

Limitations (synthesis robustness)

This is the first systematic review on the role of palliative care in the moral distress

literature. The review employed a narrative synthesis which offered the ability to discuss ideas

and theories from the included studies. A “common criticism of narrative synthesis is that it is

difficult to maintain transparency in the interpretation of the data and development of

conclusions” (NIHR CRSU, n.d.). However, the use of defined inclusion/exclusion criteria,

number of databases used, the search strategy, quality assessment of the studies, and discussion

of findings contributed to transparency and rigor.

Moral distress is not unique to nurses and recent literature has expanded its focus to

include all healthcare professionals (Whitehead, et al., 2015). There may be other empirical


studies which would have been included had the inclusion criteria not been specific to nurses.

Future research may include healthcare professionals to get a broader understanding of palliative

and end of life care training in moral distress.

The narrative synthesis was also limited by a lack of articles regarding the specific topic

and the way moral distress is measured and analyzed. Hamric (2012) shared ways researchers

can progress moral distress research and although many advancements have been made, rigorous

interventional studies continue to lag. Solid conclusions are difficult to identify given the amount

of bias and conflation in study variables, measurement, and analysis.

Conclusions

Moral distress is a conceptually complex construct. Since it’s introduction in the 70s and

80s, researchers have exhausted our understanding of how it exists in real world settings. As

Hamric (2012) encouraged, more work is needed to evaluate interventions and whether moral

distress can be mitigated when situational factors cannot. Future studies should examine moral

distress longitudinally and further refinement of the study to establish construct validity is

necessary.


References

Altaker, K. W., Howie-Esquivel, J., & Cataldo, J. (2018). Relationships among palliative care,

ethical climate, empowerment, and moral distress in intensive care unit nurses. American

Journal Critical Care, 27(4), 295-302.

Bosshardt, M., Coyne, P., Marsden, J., Su, Z., & Melvin, C. (2018). Palliative care consultation

policy change and its effect on nurses moral distress in an academic medical center.

Journal of Hospice and Palliative Nursing, 20(4), 325-329. Doi:

10.1097/NJH.0000000000000456

Browning, A. (2013). Moral distress and psychological empowerment in critical care nurses

caring for adults at end of life. American Journal of Critical Care, 22, 143-152.

Cavinder, C. (2014). The relationship between providing neonatal palliative care and nurses’

moral distress: An integrative review. Journal of Advances in Neonatal Care: Official

Journal of The National Association of Neonatal Nurses, 14, (5), 322-328. Doi:

10.1097/ANC.00000000000000100

Corley, M. (2002). Nurse moral distress: A proposed theory and research agenda. Journal of

Nursing Ethics, 9(6), 636-650.

Corley, M., Elswick, R., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral

distress scale. Journal of Advanced Nursing, 33(2), 250-256.

Corley, M. & Selig, P. (1994) Prevalence of principled thinking by critical care nurses.

Dimensions of Critical Care Nursing, 13(2), 96-103.

Dudzinski, D. (2016). Navigating moral distress using the moral distress map. Journal of

Medical Ethics, 42(5), 321-324.


Epstein, E., & Hamric, A. (2009). Moral distress, moral residue, and the crescendo effect.

Journal of Clinical Ethics, 20(4), 330.

Fourie, C. (2017). Who is experiencing what kind of moral distress? Distinctions for moving

from a narrow to a broad definition of moral distress. AMA Journal of Ethics, 19(6), 578-

584.

Gillon, R. (1985). Telling the truth and medical ethics. British Medical Journal, 291, 1556. Doi:

https://doi-org.ezproxy.uky.edu/10.1136/bmj.291.6508.1556

Hamric, A. (2012). Empirical research on moral distress: Issues, challenges, and opportunities.

HEC Forum, 24, 39-49. Doi: 10.1007/s10730-012-9177-x

Hamric, A. & Blackhall, L. (2007). Nurse-physician perspectives on the care of dying patients in

intensive care units: collaboration, moral distress, and ethical climate. Society of Critical

Care Medicine, 35(2), 422-429.

Hamric, A., Borchers, C., & Epstein, E. (2012). Development of testing of an instrument to

measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1-9.

Hamric, A., Davis, W., & Childress, M. (2006). Moral distress in health care professionals.

Pharos of Alpha Omega Alpha Honor Society, 69(1), 16-23.

Hamric, A., Whitehead, P., Prompahakul, C., & Epstein, B. (March, 2018). Updating and

refining a measure for moral distress: Introducing the measure of moral distress for

healthcare professionals (MMD-HP). Poster presented at the National Nursing Ethics

Conference Los Angeles, CA.

Higgins, J.P.T., Altman, D., Sterne, J.A.C. (2011). Chapter 8: Assessing risk of bias in included

studies. In Higgins, J.P.T., Green, S. (Eds). Cochrane Handbook for Systematic Reviews

of Interventions Version 5.1.0. Retrieved from:


http://handbook-5-1.cochrane.org/chapter_8/8_assessing_risk_of_bias_in_included_studi

es.htm

Huffman, D. & Rittenmeyer, L., (2009). How professional nurses working in hospital

environments experience moral distress: A systematic review. JBI Database of

Systematic Reviews and Implementation Reports, 7(28), 1234- 1291.

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, N.J.: Prentice-Hall.

Jameton, A. (2013). A reflection on moral distress in nursing together with a current application

of the concept. Journal of Bioethical Inquiry, 10, 297-308. Doi: 10.1007/s11673-013-

9466-3

Lamiani, G., Borghi, L., & Argentero, P. (2017). When healthcare professionals cannot do the

right thing: A systematic review of moral distress and its correlates. Journal of Health

Psychology, 22(1), 51-67. Doi: 10.1177/1359105315595120

Langley, G.C., Kisorio, L., & Schmollgruber, S. (2015). Moral distress experienced by intensive

care nurses. Southern African Journal of Critical Care, 31(2), 36-41. Doi:

10.7196/SAJCC.2015.v31i2.235

Liberati, A., Altman, D, Tetzlaff, J., Mulrow, C., Gøtzche, P., Ioannidis, P., Clark, M.,

Devereauz, P., Kleijnen, J., & Mohere, D. (2009). The PRISMA statement for reporting

systematic reviews and meta-analyses of studies that evaluate health care interventions:

Explanation and Elaboration. Annals of Internal Medicine, 6 (7), e1000100.

https://doi.org/10/1371/journal.pmed.1000100

Lützén, K., & Kvist, B. (2012). Moral distress: A comparative analysis of theoretical

understandings and inter-related concepts. Paper presented at the HEC forum.

Mareš, J. (2016). Moral distress: Terminology, theories, and models. Kontakt, 18(3), e137-e144.

https://doi.org/10/1371/journal.pmed.1000100


McAndrew, N., Leske, J., & Schroeter, K. (2016). Moral distress in critical care nursing: The

state of the science. Journal of Nursing Ethics, 1-9. Doi: 10.1177/0969733016664975

Morley, G., Ives, J., Bradbury-Jones, C., & Irvine, F. (2017). What is ‘moral distress’? A

narrative synthesis of the literature. Journal of Nursing Ethics, 1-7.

Morrison, S. & Meier, D. (2004). Palliative care. New England Journal of Medicine, 350, 2582-

2590.

Nathaniel, A. (2006). Moral reckoning in nurses. Western Journal of Nursing Research, 28(4),

419-438. Doi: 10.1177/0193945905284727

National Institute for Health Research Complex Reviews Support Unit (NIHR CRSU). (n.d.)

“Narrative synthesis”. Retrieved from

http://www.nihrcrsu.org/guidance/narrative_synthesis/.

Pauly, B., Varcoe, C., Storch, J. & Newton, L. (2009). Registered nurses’ perceptions of moral

distress and ethical climate. Journal of Nursing Ethics, 16(5), 561-573. Doi:

10.1177/0969733009106649

Rathert, C., May, D., Chung, H. (2016). Nurse moral distress: A survey identifying predictors

and potential interventions. International Journal of Nursing Studies, 53, 39-49. Doi:

http://dx.doi.org/10.1016/j.ijnurstu.2015.10.007

Rosenstein, A. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention.

American Journal of Nursing, 102, 26-34.

Ryan, R., Cochrane Consumers and Communication Review Group. (2013). “Cochrane

consumer and communication review group: Data synthesis and analysis”. Retrieved

from: http://cccrg.cochrane.org

http://cccrg.cochrane.org/


Sirilla, J. (2014). Moral distress in nurses providing direct care on inpatient oncology units.

Clinical journal of oncology nursing, 18(5).

Weissman, D. & Meier, D. (2011). Identifying patients in need of a palliative care assessment in

the hospital setting. Journal of Palliative Medicine, 14(1), 1-8.

Whitehead, P., Herbertson, R., Hamric, A., Epstein, E., Fisher, J. (2015). Moral distress among

healthcare professionals: Report of an institution-wide survey. Journal of Nursing

Scholarship, 47(2), 117-125.

Wolcott, K. (2016). Moral distress of ICU nurses and palliative care in the ICU. (Unpublished

doctoral dissertation) University of California, San Francisco.

Younjae, O. & Gastmans, C. (2013). Moral distress experienced in nurses: A quantitative

literature review. Journal of Nursing Ethics, 1-7.

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