Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search (...) and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact. (shrink)

Although moral distress is now a well-recognized phenomenon among all of the healthcare professions, few evidence-based strategies have been published to address it. In morally distressing situations, the “presenting problem” may be a particular patient situation, but most often signals a deeper unit- or system-centered issue. This article describes one institution’s ongoing effort to address moral distress in its providers. We discuss the development and evaluation of the Moral Distress Consultation Service, an interprofessional, unit/system-oriented approach to addressing and ameliorating moral (...) distress. (shrink)

Background: Moral distress has been identified as a significant issue in nursing practice for many decades. However, most studies have involved American nurses or Western medicine settings. Cultural differences between Western and non-Western countries might influence the experience of moral distress. Therefore, the literature regarding moral distress experiences among non-Western nurses is in need of review. Aim: The aim of this integrative review was to identify, describe, and synthesize previous primary studies on moral distress experienced by non-Western nurses. Review method: (...) Whittemore and Knafl’s integrative review methodology was used to structure and conduct the review of the literature. Research context and data sources: Key relevant health databases included the Ovid MEDLINE, CINAHL, Web of Science, and Google Scholar databases. Two relevant journals, Nursing Ethics and Bioethics, were manually searched. Ethical consideration: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources. Findings: A total of 17 primary studies published between 1999 and 2019 were appraised. There was an inconsistency with regard to moral distress levels and its relationship with demographic variables. The most commonly cited clinical causes of moral distress were providing futile care for end-of-life patients. Unit/team constraints (poor collaboration and communication, working with incompetent colleagues, witnessing practice errors, and professional hierarchy) and organizational constraints (limited resources, excessive administrative work, conflict within hospital policy, and perceived lack of support by administrators) were identified as moral distress’s stimulators. Negative impacts on nurses’ physical, psychological, and spiritual well-being were also reported. Conclusion: Further research is needed to investigate moral distress among other healthcare professions which may further build understanding. More importantly, interventions to address moral distress need to be developed and tested. (shrink)

Background: Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed. Objective: To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation. Methods: A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. (...) The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale. Results: Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment. Conclusions: Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness. (shrink)

Moral distress, is, at its core, an organizational problem. It is experienced on a personal level, but its causes originate within the system itself. In this commentary, we argue that moral distress is not inherently good, that effective interventions must address the external sources of moral distress, and that while there is a place for resilience in the healthcare professions, it cannot be an effective antidote to moral distress.

In their article “A Broader Understanding of Moral Distress,” Campbell, Ulrich, and Grady (2016) correctly assert that moral distress is well established in the nursing literature and is gaining at...

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and APA (...) PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions. (shrink)

The aim of this study was to explore the obligations of nurses and physicians in providing end-of-life care. Nineteen nurses and 11 physicians from a single newborn intensive care unit participated. Using content analysis, an overarching obligation of creating the best possible experience for infants and parents was identified, within which two categories of obligations (decision making and the end of life itself) emerged. Obligations in decision making included talking to parents and timing withdrawal. End-of-life obligations included providing options, preparing (...) parents, being with, advocating, creating peace and normalcy, and providing comfort. Nurses and physicians perceived obligations in both categories, although nurse obligations centered on the end of life while physician obligations focused on decision making. The findings demonstrate that, although the ultimate goal is shared by both disciplines, the paths to achieving that goal are often different. This has important implications for collaboration, communication, and improving the end of life. (shrink)

Kolbe and de Melo-Martin’s (2023) arguments draw attention to what is most useful about moral distress—identifying its causes is at least as important as measuring its severity. Jameton’s original...

Background and Objectives Primary care providers (PCPs) report decreased job satisfaction and high levels of burnout, yet little is known about their experience of moral distress. The aim of this study was to gain insight into the experiences of PCPs regarding moral distress including causative factors and proposed mitigation strategies. Methods This qualitative pilot study used semi-structured interviews to identify causes of moral distress in PCPs in an academic family medicine department. Interviews were analyzed using conventional content analysis. Results Of (...) 35 eligible participants, 12 completed the study (34% participation rate). Most were white, female, and had practiced for less than 10 years. Four PCPs had considered leaving their position due to moral distress. Participants identified five causes of moral distress: policies and procedures that conflict with patient needs, the unpredictable nature of primary care, need to “bend the rules,” lack of accountability, and lack of support staff. Six internal conflicts made resolving morally distressing situations difficult: perceived powerlessness, sense of responsibility, socialization to follow orders, emotional toll of the job, competing obligations, and fear of mistakes. Conclusions These findings matched themes in the current literature and identified an unbending infrastructure. This, coupled with the chaotic nature of primary care, resulted in frequent moral distress. Participants offered solutions to reduce and mitigate moral distress (also similar with current literature) and suggested moral distress and burnout are closely linked. (shrink)

Moral distress is a phenomenon increasingly recognized in healthcare that occurs when a clinician is unable to act in a manner consistent with his or her moral requirements due to external constraints. We contend that some experiences of moral distress are self-inflicted due to one’s under-assertion of professional authority, and these are potentially avoidable. In this article we outline causes of self-inflicted moral distress and offer recommendations for mitigation.

Background:Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand.Objective:This study aims to describe the experience of moral distress and related factors among Thai nurses.Design:A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals (...) and interview guide. The analysis was conducted separately and then integrated.Participants:Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand.Ethical considerations:This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151.Results:A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress.Discussion:Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient’s and family’s religious perspective that ties into the concept of moral distress needs to be explored.Conclusions:Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context. (shrink)

It is predicted that the rapid acquisition of new genetic knowledge and related applications during the next decade will have significant implications for virtually all members of society. Currently, most people get exposed to information about genes and genetics only through stories publicized in the media. We sought to understand how individuals in the general population used and understood the concepts of ???genetics??? and ???genes.??? During in-depth one-on-one telephone interviews with adults in the United States, we asked questions exploring their (...) basic understanding of these terms, as well as their belief as to the location of genes in the human body. A wide range of responses was received. Despite conversational familiarity with genetic terminology, many noted frustration or were hesitant when trying to answer these questions. In addition, some responses reflected a lack of understanding about basic genetic science that may have significant implications for broader public education measures in genetic literacy, genetic counseling, public health practices, and even routine health care. (shrink)

This article explores the relationship between music and ecofeminist theology and investigates how music and sound can advance the development of ecofeminist thought. On a physical level, the act of breathing connects humankind with the earth’s atmosphere and the element of air produces music and sound. On a theological level, traditional church teachings about the power and danger of music have reflected similar warnings about women and nature. Ecofeminist theologian Sally McFague made a persuasive case for metaphorical theology that supported (...) the arts being included in theological development. Religious Studies scholar Heidi Epstein engaged McFague’s metaphorical theology to develop a feminist theology of music and featured female composers including Hildegard of Bingen. I propose that metaphorical theology and music can also connect through the development of sonic metaphors. Sonic metaphors are created with pitch, rhythm, and sound. While most metaphors rely on the eyes to process written text and visual art, sonic metaphors are processed through the ears and offer different pathways for cognition. Sonic metaphors have been underutilized in theology and they offer potential for exploring theological concepts that can be challenging to comprehend through textual or visual means. These metaphors are particularly applicable for developing ecofeminist theology because sound and music can connect our bodies with nature in illuminating ways. I include examples from my own musical background, and I offer suggestions for non-musicians and ecofeminist theologians who want to incorporate sonic metaphors into their own creative theological reflection. (shrink)

Epstein et al. fail to show that L2 learners have full access to UG because they do not explain the relationship between UG and functional categories (FCs). Nor do they provide an explanation of why learners with (supposed) full knowledge of FCs fail to use them in a native-like way.

In this paper, we explore how the prospect of artificial placenta technology (nearing clinical trials in human subjects) should encourage further consideration of the loss experienced by individuals when their pregnancy ends unexpectedly. Discussions of pregnancy loss are intertwined with procreative loss, whereby the gestated entity has died when the pregnancy ends. However, we demonstrate how pregnancy loss can and does exist separate to procreative loss in circumstances where the gestated entity survives the premature ending of the pregnancy. In outlining (...) the value that can be attached to pregnancy beyond fetal-centric narratives, we illustrate how pregnancy loss, separate to procreative loss, can be experienced. This loss has already been recognised among parents who have experienced an unexpected early ending of their pregnancy, resulting in their child being cared for in neonatal intensive care unit. Artificial placentas, however, may exacerbate these feelings and make pregnancy loss (without procreative loss) more visible. We argue that pregnancy is an embodied state in which gestation is facilitated by the body but gestation itself should be recognised as a process—and one that could be separable from pregnancy. In demarcating the two, we explore the different ways in which pregnancy loss can be understood. Our objective in this paper goes beyond contributing to our philosophical understanding of pregnancy towards practical-orientated conclusions regarding the care pathways surrounding the artificial placenta. We make recommendations including the need for counselling and careful consideration of the language used when an artificial placenta is used. (shrink)

If the world itself is metaphysically indeterminate in a specified respect, what follows? In this paper, we develop a theory of metaphysical indeterminacy answering this question.

What do we mean when we call a work of art "beautiful"? How have artists responded to changing notions of the beautiful? Which works of art have been called beautiful, and why? Fundamental and intriguing questions to artists and art lovers, but ones that are all too often ignored in discussions of art today. Elizabeth Prettejohn argues that we simply cannot afford to ignore these questions. Charting over two hundred years of western art, she illuminates the vital relationship between (...) our changing notions of beauty and specific works of art, from the works of Kauffman to Whistler, Ingres to Rosetti, Cezanne to Pollack. Beautifully illustrated with 100 photographs--60 in full color--Beauty and Art concludes with a challenging question for the future: Why should we care about beauty in the twenty-first century? (shrink)

This new and important study of semantic change examines how new meanings arise through language use, especially the various ways in which speakers and writers experiment with uses of words and constructions in the flow of strategic interaction with addressees. In the last few decades there has been growing interest in exploring systemicities in semantic change from a number of perspectives including theories of metaphor, pragmatic inferencing, and grammaticalization. Like earlier studies, these have for the most part been based on (...) data taken out of context. This book is the first detailed examination of semantic change from the perspective of historical pragmatics and discourse analysis. Drawing on extensive corpus data from over a thousand years of English and Japanese textual history, Traugott and Dasher show that most changes in meaning originate in and are motivated by the associative flow of speech and conceptual metonymy. (shrink)

In this chapter I address the concern that UNESCO World Heritage designation leads to unregulated tourism. I argue that heritage tourism not only has a negative impact on the site but may adversely impact local populations and descendant communities. I detail two related worries, UNESCO-cide and the Disneyfication of cultural heritage. The term ‘UNESCO-cide’ was coined by Marco d’Eramo to describe the role overtourism has played in the death of cities listed on UNESCO’s World Heritage list. Disneyfication is the process (...) of sanitizing potentially controversial or seemingly negative narratives from the tourist site to make the experience more palatable. I focus my analysis on two UNESCO World Heritage sites: Angkor Archaeological Complex in Cambodia and George Town in Malaysia. After a discussion about the negative impacts World Heritage designation has had on these sites, I suggest some mitigating strategies for tourism. (shrink)

One of the alleged advantages of a constructivist theory in metaethics is that the theory avoids the epistemological problems with moral realism while reaping many of realism's benefits. According to evolutionary debunking arguments, the epistemological problem with moral realism is that the evolutionary history of our moral beliefs makes it hard to see how our moral beliefs count as knowledge of moral facts, realistically construed. Certain forms of constructivism are supposed to be immune to this argument, giving the view a (...) key advantage. This paper considers the challenge that evolutionary debunking arguments pose for the possibility of moral knowledge and concludes that such arguments do not reveal any advantages for constructivism. Furthermore, once we consider how defenders of moral knowledge should best respond to this epistemological objection, constructivists may face more difficulties, not less, explaining how our moral beliefs represent moral knowledge. (shrink)

Part of the Blackwell Readings in the History of Philosophy series, this survey of late modern philosophy focuses on the key texts and philosophers of the period whose beliefs changed the course of western thought.

This comprehensive and up-to-date textbook gives a clear account of the different philosophical and theoretical approaches to psychology and discusses major philosophical questions such as free will and the relation between mind and body.

Our language system is ambiguous in that the same utterance can be interpreted in different ways depending on the intention of the speaker. For example, the phrase, “Nice job!” can be interpreted a...

A theoretical platform for a much‐needed change in the provision of healthcare based on restoring the autonomy of doctor–patient relationships.

Since the late 1960s, the legal doctrine of consent has occasionally been subject to severe criticism from within the bioethical discourse. The criticism was often based on observations indicating that consents and refusals, which had been considered valid from legal or institutional points of view, had frequently failed to reflect genuinely autonomous decision making, hence genuinely autonomous choices.This has led several critics to conclude that informed consent is a legal fiction. To clarify the concept, a legal fiction is a supposition (...) of fact taken to be true by the courts of law, irrespective of whether it is true or not, and even though it might not be true .1 What these critics probably meant to say was that the law deems any person who has given a legally valid consent to be genuinely task specifically autonomous, regardless of whether this is true or not and even though it might not be true. In other words, informed consent is a legal fiction, since it presupposes—that is, claims to reflect—genuine task specific autonomy, however baselessly.It was precisely this potentially embarrassing conclusion that prompted Faden and Beauchamp to develop a brilliant and remarkably effective argument in defence of the legal doctrine of consent. In their seminal work, AHistory and Theory of Informed Consent, they indeed acknowledged that effective consent often fails to be compatible with autonomous authorisation . Indeed, they recognised that effective consent does not necessarily entail autonomous authorisation. They argued, however, that the former is not a legal fiction, since it does not presuppose the …. (shrink)

Introduction: human rights in healthcare -- A right to treatment? the allocation of resouces in the National Health Service -- Ensuring quality healthcare: an issue of rights or duties? -- Autonomy and consent in medical treatment -- Treating incompetent patients: beneficence, welfare and rights -- Medical confidentiality and the right to privacy -- Property right in the body -- Medically assisted conception and a right to reproduce? -- Termination of pregnancy: a conflict of rights -- Pregnancy and freedom of choice (...) -- The right to life at the end of life -- The law and ethics of assisted dying: is there a right to die? (shrink)

The recently published Report of theAHAG on the Operation of NHS Research Ethics Committees advocates major reforms of the NHS research ethics committees system. The main implications of the proposed changes and their probable effects on the major stakeholders are described.The Ad Hoc Advisory Group on the operation of NHS research ethics committees, set up in November 2004 by Lord Warner on behalf of the Department of Health, submitted its report in June 2005.1 The report advocates major reforms of the (...) research ethics committee system. The primary aim of the report is to streamline the processes around the approval of research projects and to pursue conformity of governance across Europe. Implicit in the report is the contention that failure to achieve this objective would be harmful to everyone with vested interests in improving health and social care. Moreover, it is stated that the reforms will enhance the mechanisms that protect the interests of all parties concerned.1Being mindful of two published critiques of the Warner Report, we suggest that its alleged benefits should not be taken at face value.2,3 In fact, the reformed system will give rise to moral failings akin to those of the existing system, but will differ from the existing system in its effect on the stakeholders. Thus, whereas the outgoing system has given each stakeholder a unique mixture of benefit and harm, the incoming system offers benefit only to sponsors and researchers and nothing but detriment to participants in research and consumers of its products.In the light of this conclusion, we finally suggest that the Warner Report be construed not merely as an ill-considered document, but rather as an ideological reflection of a long-established hegemonic contract fine-tuning itself to contemporary global challenges.To avoid …. (shrink)

Recruitment and Reproduction: The Careers and Carriers of Digital Photography and Floorball The claim that social practices have a relatively durable existence in space and time, and that their persistence depends upon their recurrent reproduction through necessarily localised performances is theoretically plausible, but what of the detail? How do the careers of practices and those who "carry" them actually intersect? In this paper we have two related ambitions. One is to show how selected practices are concurrently shaped by the ebb (...) and flow of recruits and defectors and by what it is that cohorts of practitioners actually do. The second is to learn more about the relation between recruitment and reproduction by comparing the ways in which these processes play out in different situations. In taking these two ambitions forward through a discussion of digital and film photography and of floorball (a team game in which players use plastic sticks to hit a small ball into a goal) we explore ways of concretely examining processes that are implied in Giddens' theory of structuration (1984) and in Bourdieu's concept of habitus (1984). This exercise generates insights into the internal dynamics of practice and the methodological challenges of pinning them down. (shrink)

This class-tested text provides a comprehensive overview of the classical and current theories of moral development and applications of these theories in various counseling and educational settings.

The importance of food in our individual lives raises moral questions from the debate over eating animals to the prominence of gourmet cookery in the popular media. Through philosophy, Elizabeth Telfer discusses issues including our obligations to those who are starving; the value of the pleasure of food; food as art; our duties to animals; and the moral virtues of hospitableness and temperance. Elizabeth Telfer shows how much traditional philosophy, from Plato to John Stuart Mill, has to say (...) to illuminate this everyday yet complex subject. (shrink)

Conferralism is the view that social properties are neither intrinsic to the things that have them nor possessed simply by virtue of their causal or spatiotemporal relations to other things, but are somehow bestowed (intentionally or not, explicitly or not) upon them by persons who have both the capacity and the standing to bestow them. We argue that conferralism faces a dilemma: either it is viciously circular, or it is limited in scope in a way that undercuts its motivation.

This paper defends the avowal view of self-deception, according to which the self-deceived agent has been led by the evidence to believe that ¬p and yet is sincere in asserting that p. I argue that the agent qualifies as sincere in asserting the contrary of what they in the most basic sense believe in virtue of asserting what they are committed to believing. It is only by recognizing such commitments and distinguishing them from the more basic beliefs whose rational regulation (...) is automatic that the tension between the self-deceived agent’s actions and assertions can be explained in a core subset of cases of self-deception. (shrink)

In this article we examine the association between national welfare regime and the propensity of middle–aged and older individuals with adult children of their own to provide social support to aged parents. Using data from mature adults (50+) in 26 European countries, we examine whether older and younger generations compete for the time resources of the middle “sandwiched” generation, and whether national policy context shapes this competition. Contrary to expectations, we found that sandwich generation members were less likely to provide (...) support to their parents in Conservative–Mediterranean and East European regimes, but more likely to do so in universalistic Social–Democratic regimes. This evidence supports the hypothesis that well–developed welfare states “crowd–in” family support to older individuals. Middle generation members who provided social support to their adult children tended to provide to their older parents as well. This was particularly true in the two regimes where resources and public benefits tend to be more generous and may be interpreted as state benefits that reduce intergenerational competition. Findings are discussed in terms of the capacity of state policies to shape the allocation of family resources to older adults where extended family lineages have become the norm. (shrink)

This book looks at business ethics from the perspective of the business practitioner, but with the rigour of the moral philosopher. Intended for introductory students of business, commerce and management studies, Business Ethics at Work begins by setting business clearly in the context of creating value for its owners, and develops a practical ethical decision model which can be simply and relevantly applied to the hard moral choices with which business people are faced day to day. Against this background, some (...) of the major ethical issues which arise in business are explored, for example, in human resource management, finance, marketing and advertising, the management of the environment and corporate governance. In conclusion the book looks at the nature of ethical audit and argues that for the business of the future, the identification of its ethical values and their integration into its policies and practices will be a crucial ingredient of success. (shrink)