Read the article,?Moral Distress and Psychological Empowerment in Critical Care Nurses Caring for Adults at End of Life. Identify common causes of moral distress in critical care nurses

Notice to CNE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:

1. Identify common causes of moral distress in critical care nurses who are caring for dying patients.

2. Describe the concept of psychological empow- erment and the 4 cognitions it encompasses.

3. Discuss the study findings as related to the relationship between moral distress intensity and frequency, psychological empowerment, and participant demographics.

To read this article and take the CNE test online, visit www.ajcconline.org and click “CNE Articles in This Issue.” No CNE test fee for AACN members.

By Annette M. Browning, RN, PhD, CNS

Background Critical care nurses providing care for adults at

the end of life may encounter moral distress when they cannot

do what they believe is ethically correct. Psychological empow-

erment can decrease moral distress among critical care nurses.

Objectives To describe the relationships between moral dis-

tress, psychological empowerment, and demographics in criti-

cal care nurses caring for patients at the end of life.

Method A total of 277 critical care nurses were surveyed via

the Moral Distress Scale and the Psychological Empowerment

Instrument. Responses were scored on a Likert scale of 1 to 7.

Results Moral distress intensity was high (mean 5.34, SD 1.32)

and positively correlated with age (r = 0.179, P = .01). Moral

distress frequency was moderate (mean 2.51, SD 0.87) and

negatively correlated with nurses’ collaboration in end-of-life

patient care conferences (r = -0.191, P = .007). Psychological

empowerment scores (mean 5.31, SD 1.00) were high and

positively correlated with age (r = 0.139, P = .03), years of

experience (r = 0.165, P = .01), collaboration in end-of-life-care

conferences (r = 0.163, P = .01), and end-of-life-care education

(r = 0.221, P = .001) and were negatively correlated with moral

distress frequency (r = -0.194, P = .01). Multiple regression

analysis revealed that empowerment was a significant predic-

tor of moral distress frequency (β= .222, P < .01).

Conclusion The significant negative correlation between psy-

chological empowerment and frequency of moral distress in

these nurses indicated that nurses with higher perceived empow-

erment experience moral distress less often. This finding is of

particular interest as interventions to decrease moral distress

are sought. (American Journal of Critical Care. 2013;22:143-152)

MORAL DISTRESS AND

PSYCHOLOGICAL

EMPOWERMENT IN CRITICAL

CARE NURSES CARING FOR

ADULTS AT END OF LIFE

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© 2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2013437

Challenges in the Critical Care Workplace

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Background The advent of life-support technology during the

past half century has drastically changed the focus of caring for dying patients. Critical care units were developed in order to monitor critically ill patients appropriately, and critical care nurses were provided specialized education for the purpose of providing optimal care for critically ill patients. Although advanced technology has brought with it the prom- ise of more efficient treatment techniques, extending life inappropriately and futile prolonging of patients’ suffering have become commonplace for critical

care nurses caring for dying patients,6

thus causing moral distress in critical care nurses.

Jameton7 was the first to define moral distress in the nursing literature. Moral distress was defined as discom- fort or internal conflict related to ethi- cal dilemmas encountered in nursing practice when constraints prevented the nurse from following the course

of action believed to be right. Obstacles contributing to the inability to act upon what the nurse believes to be right have many origins. Beckstrand and Kirchhoff1 identified several obstacles that 864 criti- cal care nurses perceived while providing end-of-life care, including the perception that their opinions related to end-of-life care decisions were not being recognized and valued. The highest ranking obstacles

in this study were as follows: Families not under- standing the term “life-saving measures” and its implications, families requesting life-saving measures contrary to patients’ wishes, and patients’ treatments continuing although painful or uncomfortable.

In 2006, the American Association of Critical- Care Nurses (AACN) identified end-of-life care chal- lenges as a significant source of moral distress in critical care nurses. AACN has issued a position statement on moral distress, proclaiming it a serious problem in nursing.8

Psychological empowerment is a mechanism by which people gain mastery of their affairs.9 In the nursing literature, empowerment has been examined on the basis of 2 conceptualizations, structural and psychological. Psychological empowerment (one’s belief in one’s ability to be empowered) was meas- ured in this study.

As critical care nurses develop a more active voice in collaboration with physicians, ethics com- mittees, and members of the multidisciplinary health care team, the facilitation of empowerment among nurses might decrease moral distress and enhance patient care outcomes at the end of life. No studies have been reported to date that specifically examine the relationship between moral distress and empow- erment in nursing thus, in this study, we sought to determine if such a relationship exists.

Moral Distress Related to End-of-Life Care

Several studies have associated levels of moral distress in nurses with the delivery of end-of-life care to patients.10-12 In most of the studies reviewed, the most common phenomenon related to end-of-life care that is causing moral distress in critical care nurses is the delivery of futile care. The delivery of futile care at the end-of-life was first examined by Wilkinson,13 who

One-fifth of the patients cared for by critical care nurses die in the intensive care unit.1 The American Association of Colleges of Nursing2 has expressed growing concern about an increase in the use of inappropriate life-support treatments related to end-of-life care. In the past decade, awareness of potential inadequacies in caring for the dying has been increasing, and

many of these inadequacies are related to the use of life support in critical care settings.3 In cases of futility, aggressive medical treatment at the end of life is well documented as a cause of moral distress in critical care nurses.4 Moral distress occurs when nurses are unable to per- form according to what they believe to be ethically correct. Increasing psychological empow- erment in nurses is a means of strengthening the impact that nurses have to innovatively influence decision making related to patient care.5 Increasing psychological empowerment may be a means of ameliorating moral distress in critical care nurses caring for dying adults.

About the Author Annette M. Browning is an associate professor of nursing and director of simulation learning at Biola University, La Mirada, California.

Corresponding author: Annette M. Browning, RN, PhD, CNS,

982 Big Sky Lane, Orange, CA 92869 (e-mail: annette. [email protected]).

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Moral distress occurs when

nurses are unable to do what they

believe to be ethically correct.

by AACN on July 20, 2017http://ajcc.aacnjournals.org/Downloaded from

4 consecutive weeks. If subscribers were interested in participating, they used a link that led them to the online survey, which started with a cover letter explaining the details of the study further.

Data Collection (Instruments and Procedure)

Two valid and reliable survey instruments were used in this study, the 32-item Moral Distress Scale (MDS)10 and the 16-item Psychological Empower- ment Instrument (PEI)22 in addition to the demo- graphic data survey (see Figure). The MDS-32 has been tested for content validity twice.23 All items were considered relevant in both testings. Test-retest relia- bility of the MDS-32 was 0.86 (P= .01).23 The high reliability may reflect redundancy of some items. The Cronbach alpha was 0.93 (P< .01), demonstrating high reliability. The MDS was later expanded to 38 items. These additional items were unrelated to end- of-life care, so the original 32-item MDS was used.

The MDS measures moral distress intensity, the level at which the nurse experiences painful feelings related to a given situation (none to great extent), and moral distress frequency, how often the nurse experi- ences the painful feeling associated with the distress- ful situation (never to very frequently) on a Likert scale from 1 to 7. The MDS uses 3 factors or subscales to measure moral distress: (1) individual responsibil- ity (refers to the nurse participating in care not agreed with or ignoring actions one should take—20 items), (2) not in patient’s best interest (refers to participating

built on the work of Jameton.7 Multiple studies4,10,13-18

have shown that futile care, where nurses perceived that the patient would not benefit from care, caused the most significant levels of moral distress in nurses.

Theories of Psychological Empowerment

Bandura19 theorized that degrees of empower- ment are perceived as one’s sense of self-efficacy is facilitated. Self-efficacy occurs when one’s sense of self-determination is strengthened or one’s sense of powerlessness is weakened. Furthermore, the strength of one’s perceived empowerment determines how obstacles are viewed and the degree to which one overcomes the obstacles.20

Conger and Kanungo21 took self-efficacy a step further by reiterating that true empowerment occurs when convictions of one’s own effectiveness are suc- cessfully executed and not merely hoped for. Thomas and Velthouse9 further postulated empowerment as multifaceted, encompassing 4 cognitions: (1) meaning, the value one attaches to one’s standards, (2) competence, the belief that one is able to carry out one’s beliefs in action, (3) self-determination, the sense that one has control over one’s autonomy, and (4) impact, the degree to which one perceives one’s work as having influence.

Conceptual Framework Although critical care nurses may perceive them-

selves as having some degree of empowerment with respect to decision making related to end-of-life care, they see themselves as often unable to contribute significantly to decisions they believe to be correct. This “gap” between nurses having empirical knowl- edge and not being able to apply that knowledge effectively was the impetus for this study intended to explore the association between moral distress intensity, moral distress frequency, psychological empowerment, and select demographics of critical care nurses (see Figure).

Methods Sample

A cross-sectional descriptive survey design was used to study a target population of critical care nurses caring for adults at the end of life. A sample of 277 critical care nurses who were on AACN’s e-mail newsletter list were recruited for this study. Inclusion criteria were as follows: (1) must be a critical care staff nurse and (2) must have had experience with caring for dying adults in the critical care setting before completing the survey tools. A brief paragraph describ- ing the study was placed in the AACN newsletter for

Figure Conceptual framework for the relationship between moral distress (intensity and frequency), psychological empowerment, and select demographics.

Abbreviations: AACN, American Association of Critical-Care Nurses; ELNEC, End-of- Life Nursing Education Consortium.

Psychological empowerment

• Meaning

• Competence

• Self-determination

• Impact

Moral distress Intensity

Frequency

• Not in patient’s best interest

• Individual responsibility

• Deception

Nursing characteristics

• Age

• Number of years in critical care

• Level of education

• Work status

• AACN membership

• AACN specialty certification

• Active collaboration in end-of- life patient care conferences

• ELNEC critical care training

• End-of-life care continuing education (within past year)

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in care that the nurse considers inappropriate because of futility for the patient— 7 items), and (3) decep- tion (refers to the nurse not addressing issues hon- estly, related to impending death of a patient—3 items). Data from 2 items (12 and 13) on the MDS-32 pertain to children. These 2 items were omitted from the tables presented here because of the study’s focus on the care of adults; however, all 32 items were administered in the survey given to participants.

The PEI is highly reliable and valid,22,24 with reported reliability coefficients ranging from 0.62 to 0.74. The PEI used 4 domains or subscales, previously defined, to measure psychological empowerment: (1) meaning, (2) competence, (3) self-determination, and (4) impact. Each domain addressed 4 items (see Figure) measuring empowerment. Items were scored as follows: 7 = very strongly agree, 6 = strongly

agree, 5 = agree, 4 = neutral, 3 = dis- agree, 2 = strongly disagree, 1 = very strongly disagree.

Quantitative data were collected from October 28, 2010 to November 25, 2010. From the approximately 80 000 e-mailed newsletters, 277 recipients returned the survey. The return rate was approximately 0.35%.

Participants were excluded from analyses when they left 25% or more responses blank on any given measure. For example, if a participant left 4 out of 10 responses blank on the MDS, they were left out of analyses comparing moral distress scores with other scale scores. They were included, however, in the descriptive statistics for other measures that were sufficiently completed (<25% missing).

Approval by the institutional review board of the University of San Diego for the protection of human subjects was obtained for this study. The institutional review board determined that written informed consent was not required. A cover letter approved by the institutional review board was posted on the AACN Web site, informing readers about the follow- ing information: that participation in the study was voluntary and study data were kept confidential, risks and benefits of participation, and how to contact the investigator for questions. The participants were assured of their anonymity both in data collection and the publication of data. All data were stored on a pass- word-protected computer. No identifying information, including e-mail addresses, was included in the Excel spreadsheet uploaded from SurveyMonkey.

Statistical Analysis and Variables

Percentages were used to describe the categorical variables. Appropriate correlational statistics, based

on variable level of data (continuous or categorical), were used to examine relationships among variables. Moral distress intensity and moral distress frequency were 2 separate dependent or outcome variables measured by the MDS. Multiple linear regression analysis was used to examine associations between the dependent variable of moral distress intensity and the independent or predictor variables (psycho- logical empowerment and demographics) and the dependent variable of moral distress frequency and the independent or predictor variables (psychologi- cal empowerment and demographics).

Results The following demographics were found within

the sample: The participants had a mean age of 46.9 years (SD 10.4). The mean number of years of experi- ence working as a critical care nurse was reported as 17.45 (SD 11). Most participants (n = 234, 84.5%) were working full-time in critical care. The percentage of participants employed part-time was 11.6% (n=32). Only 1 participant was working per diem. More than half of the nurses (54.6%) reported being active par- ticipants in end-of-life patient care conferences. Most of the responding nurses had a bachelor of science degree in nursing (47.1%); 29.2% of the participants had an associate degree in nursing; 19.7% of the nurses had a master of science degree in nursing, and 3.3% of the participating nurses were doctorally prepared. Most of the participants (55.2%) had specialty certi- fication by the AACN, and most participants (54.6%) also reported having had end-of-life care education within the past year. A large majority of participating nurses (86%) reported being members of the AACN. Only 5.8% of the participants (n=16) reported partic- ipation in the critical care training provided by the End-of-Life Nursing Education Consortium (ELNEC).

Moral Distress Intensity and Moral Distress

Frequency

Moral distress intensity and moral distress fre- quency scores ranging from 0 to 2.33 were considered low, 2.34 to 4.66 moderate, and 4.67 to 7.00 high. Scores for moral distress scale subscales and total scores were calculated separately for both intensity and frequency (Table 1).

Mean scores for items on the moral distress intensity scale ranged from 4.39 to 6.05, with a overall mean total score of 5.34 (SD 1.32). The 3 highest-scoring items for moral distress intensity were “assisting [physician] who in my opinion is providing incompetent care” (mean 6.05), “work in a situation when the number of staff is too low and care is inadequate” (mean, 5.97), and “continue

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Most participants reported having had

end-of-life care education within

the past year.

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Table 1 Moral distress intensity and frequency of respondents (N=277) according to subscales: not in patient’s best interest, individual responsibility, and deception

Not in patient’s best interest

Individual responsibility

Deception

1. Follow family’s wishes for patient care I don’t agree with

2. Follow family’s wishes to continue life support when not in patient’s best interest

3. Follow physician’s orders for unnecessary tests

5. Initiate life-saving actions when I think it prolongs death

15. Carry out physician’s orders for unnecessary tests and treatments on terminally ill patients

22. Prepare a terminally ill elderly patient receiving mechanical ventilation for surgery to have a mass removed

23. Prepare an elderly severely demented patient who is a no code for placement of a gastrostomy tube

Not in patient’s best interest subscale score

4. Assist physician who performs test or treatment without patient’s consent

6. Ignore situations of suspected abuse of patient by caregivers

7. Ignore situations of inadequate consent from patient

8. Perform procedure when the patient is not adequately informed

9. Carry out work assignment in which I do not feel professionally competent

10. Avoid taking action when a nurse colleague has made a medication error

11. Let medical students perform painful procedures on patients solely to increase their skill

14. Assist physicians practicing procedures on a patient after cardiopulmonary resuscitation has been unsuccessful

16. Work with “unsafe” levels of nurse staffing

17. Carry out order to discontinue treatment because patient can no longer pay

18. Continue to care for a hopelessly injured patient receiving mechanical ventilation when no one will discontinue the ventilation

19. Observe without intervening when personnel do not respect patient’s dignity

20. Follow physician’s order not to tell patient the truth when he/she asks for it

21. Assist physician who in my opinion is providing incompetent care

24. Discharge patient based on diagnosis-related groups although he has many teaching needs

25. Provide better care for those who can afford to pay

26. Follow the family’s request not to discuss dying with a dying patient who asks about dying

27. Follow physician’s request not to discuss death with a dying patient who asks about dying

28. Work in a situation when the number of staff is too low and care is inadequate

32. Follow physician’s request not to discuss code status with family when patient is incompetent

Individual responsibility subscale score

29. Give medications intravenously during a code with no compressions or intubation

30. Give only hemodynamic stabilizing medications intravenously during a code with no compression or intubation

31. Follow physician’s request not to discuss code status with patient

Deception subscale score

Total of all subscales

4.81 (1.52)

5.47 (1.46)

5.22 (1.53)

5.72 (1.46)

4.39 (2.18)

5.09 (1.91)

5.24 (1.87)

5.13 (1.25)

5.27 (2.08)

5.51 (2.16)

5.42 (1.76)

5.36 (1.71)

5.27 (1.95)

4.89 (1.84)

5.40 (2.09)

5.09 (2.35)

5.82 (1.56)

5.36 (2.39)

5.88 (1.50)

5.67 (1.68)

5.83 (1.78)

6.05 (1.56)

5.15 (2.04)

5.20 (2.23)

5.79 (1.74)

5.76 (1.86)

5.97 (1.72)

5.50 (2.03)

5.50 (1.47)

4.68 (2.18)

4.49 (2.20)

5.54 (2.05)

4.92 (1.82)

5.34 (1.32)

4.08 (1.66)

4.45 (1.65)

4.28 (1.80)

3.73 (1.71)

3.71 (1.77)

2.42 (1.41)

3.17 (1.67)

3.69 (1.22)

2.01 (1.44)

1.60 (1.17)

2.22 (1.52)

2.21 (1.46)

1.91 (1.12)

2.05 (1.20)

2.00 (1.52)

1.45 (1.15)

3.57 (1.88)

1.43 (1.26)

3.61 (1.81)

2.21 (1.68)

1.86 (1.24)

2.49 (1.36)

1.95 (1.43)

1.67 (1.40)

2.22 (1.27)

1.98 (1.33)

2.91 (1.79)

1.91 (1.43)

2.15 (0.88)

2.29 (1.506)

2.30 (1.46)

1.87 (1.37)

2.16 (1.20)

2.51 (0.87)

Subscale Item Intensity Frequency

Mean (SD)

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to care for a hopelessly injured patient on a ventila- tor when no one will discontinue the ventilator” (mean 5.88). The lowest-scoring item for moral dis- tress intensity was “carry out [physician]’s orders for unnecessary tests and treatments on terminally ill patients” (mean 4.39).

Mean scores for items on the moral distress fre- quency scale ranged from 1.43 to 4.45, with an overall mean total of 2.51 (SD 0.87). The 3 highest-scoring items for moral distress frequency were “follow family’s wishes to continue life support when not in patient’s best interest” (mean 4.45), “follow [physician]’s orders for unnecessary tests” (mean 4.28), and “follow family

wishes for patient care I don’t agree with” (mean 4.08). The lowest-scoring item for moral distress frequency was, “carry out order to discontinue treat- ment because patient can no longer pay” (mean 1.43).

Total scores for both moral dis- tress intensity and moral distress fre- quency were determined for each of

the 3 subscale categories (Table 1). All moral distress intensity subscale totals were high: (1) not in patient’s best interest (mean 5.13, SD 1.25), (2) individual responsibility (mean 5.50, SD 1.47), and (3) decep- tion (mean 4.92, SD 1.82).

Moral distress frequency subscales were as follows: (1) not in patient’s best interest (mean 3.69, SD 1.22), (2) individual responsibility (mean 2.15, SD 0.88), and (3) deception (mean 2.16, SD 1.43). The total score for moral distress intensity was high (mean 5.34, SD 1.32), and the total score for moral distress frequency was moderate (mean 2.51, SD 0.87).

Psychological Empowerment

The PEI was used to determine levels of empow- erment of critical care nurses in the workplace. Data from this instrument were scored in the following manner: individual item mean scores, mean subscale scores, and a mean total score. Similar to moral dis- tress, PEI scores from 0 to 2.33 were considered low, 2.34 to 4.66 moderate, and 4.67 to 7.00 high.

PEI items ranged from moderate (mean 3.88) to high (mean 6.22). The highest scoring PEI item was, “I really care about what I do on my job” (mean 6.22, SD 1.16). The lowest scoring item was, “I have a great deal of control over what happens in my department” (mean 3.88, SD 1.52). PEI subscale scores were all high: meaning (mean 6.06, SD 1.09), competence (mean 5.92, SD 1.02), self-determination (mean 5.03, SD 1.18), and impact (mean 4.22, SD 1.47). Overall, the total PEI mean score indicated a high degree of psychological empowerment (mean 5.31, SD 1.00).

Correlational Analysis of Moral Distress and

Demographics

Weak but significant positive correlations were found between the moral distress item “not in patient’s best interest” and age (r= 0.179, P= .01) and ELNEC critical care training (r= 0.185, P= .008). Likewise weak but significant positive correlations were found between ELNEC training and the items “not in patient’s best interest” (r= 0.194, P= .006) and total score for moral distress frequency (r=0.165, P= .02). A weak but significant negative correlation was found between active collaboration in end-of- life patient care conferences and items related to deception (r= -0.191, P= .007).

Correlational Analysis of Empowerment and

Demographics

Several significant positive correlations were found between psychological empowerment and the nurses’ demographics (Table 2). Significant and moderate correlations were found between empow- erment related to competence and years of critical care experience (r= 0.255, P= .001). Other moderate and significant correlations were found between empowerment related to self-determination and col- laboration in end-of-life care conferences (r= 0.217, P= .001) and end-of-life care education in the past year (r= .209, P= .001). In addition, a significantly po

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