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Abstract

The global pandemic has intensified the risk of moral distress due to increased demands on already limited human resources and uncertainty of the pandemic’s trajectory. Nurses commonly experience moral distress: a conflict between the morally correct action and what they are required or capable of doing. Effective moral distress interventions are rare. For this reason, our team conducted a multi-phase research study to develop a moral distress intervention for pediatric critical care nurses. In this article, we discuss our multi-phase approach to develop a moral distress intervention—proactive, interdisciplinary meeting. Our proposed intervention is a sequential compilation of empirical work couched within a relational ethics lens thus should point to enhanced potential for intervention effectiveness.

Keywords

Critical care intervention development moral distress nurses relational ethics

Introduction

The global pandemic has created unprecedented challenges for healthcare professionals. During this time, healthcare professionals are exposed to new ethical situations due to increased demands on limited resources, confusion related to constantly changing guidelines, and redeployment. These challenges intensify the moral distress nurses routinely experience in their clinical practice.^1,2 Moral distress is notably higher in critical care, than in other clinical areas. Additionally, healthcare professionals in pediatric and neonatal critical care units have higher levels of moral distress than those working in adult critical care and pediatric wards.³

Interventions to mitigate the negative effects of moral distress are vital to improve nurse’s health, patient care, and the workplace environment. In this article, we describe our multi-phase approach to developing a moral distress intervention—a relational ethics-informed proactive, interdisciplinary meeting. We describe the process and rationale used to develop the intervention and use the Template for Intervention Description and Replication (TIDieR checklist)⁴ to inventory all intervention components. This novel intervention has the potential to minimize the negative effects of moral distress and improve the working lives of nurses.

Background

Moral distress is defined as a situation that arises when one experiences a conflict between what they feel is the ethically correct action and what they are required or capable of doing. A particular event does not cause moral distress; rather it is due to a given situation and the beliefs, values, and wishes of all those involved.^5,6 At the individual level, examples of contributing factors include feeling powerless or inadequate,⁷ while environmental or system-based factors include the power dynamics among those involved in the situation, lack of resources or support, and conflicts among the healthcare team.^8,9 A national survey examining moral distress among intensive care unit (ICU) healthcare professionals showed that perceived hospital supportiveness was significantly negatively associated with levels of moral distress.¹⁰

Moral distress can negatively affect the individual emotionally, psychologically, spiritually, and physically.^11,12 Symptoms that one might experience include heart palpitations, insomnia, headaches, fatigue, depression, anxiety, burnout, and loss of self-worth.^11,13 The individual experiencing moral distress can develop ineffective coping strategies (e.g., avoiding or withdrawing from patient situations) leading to poor quality patient care and decreased patient satisfaction.^14,15 According to Prentice et al.,⁷ 72% of healthcare professionals experience moral distress at least once a month. While Norman et al.¹⁶ found that 87.8% of healthcare professionals in New York City who responded to their survey (n = 6026) experienced moral distress during the peak of the pandemic (April 14–May 11, 2020).

Moral distress also negatively affects the retention of healthcare professionals.^17,18 In the ICU, nearly half of nurses, up to half of physicians, and half of other healthcare professionals (such as respiratory therapists, social workers, and pharmacists) who experienced moral distress have considered leaving or left their position.^19–21 Due to the high rates of turnover associated with moral distress in the ICU,^19,20,22,23 particularly within the pediatric ICU,^3,7,10 supporting healthcare professionals through their experiences of moral distress is a priority.²⁴ Since Andrew Jameton first defined the concept in 1984, moral distress research has primarily focused on understanding its experiences, causes, and effects. There is a lack of evidence-based interventional studies to address the negative effects of moral distress.²⁵ The crucial next step in moral distress research is developing effective interventions, particularly in pediatric critical care.

According to the Medical Research Council,²⁶ using a relevant theory is more likely to result in an effective intervention than evidence alone. Relational ethics is a lens that reflects the complexities of daily ethical situations and can further our understanding of morally distressing situations.²⁷ This lens assumes ethical challenges occur between people, and therefore ethical situations are not viewed as having one clear outcome.²⁸ The foundation of relational ethics is that the space between oneself and the other is where moral action lies. Within this moral space genuine dialogue can occur, and relationships can flourish. This dialogue is the place where we can see the other person for who they are, recognize their uniqueness, and appreciate their differences.²⁹ This ethic has four key elements: mutual respect, engagement, embodied knowledge, and the interdependent environment.²⁸ Within open dialogue, each of these elements can be enacted. Moral distress occurs because of a rupture in relationships, and possibly one way to mend this rupture is through relational ethics. Relational ethics can allow us to understand morally distressing situations better and therefore has the potential to minimize the negative effects of moral distress.²⁷ Thus, relational ethics was selected in place of a theory because this ethic recognizes that ethical practice is situated within relationships while acknowledging the influence the environment has on guiding ethical action.²⁷

In this paper, we explore the third and final phase of the research study, developing an evidence-and-ethic informed intervention to minimize the negative effects of moral distress among pediatric critical care nurses.

Methods

Based on the taxonomy of O’Cathain and colleagues,³⁰ we chose the evidence and theory-based intervention development approach to guide our moral distress intervention. Specifically, we used a three-phase approach to develop an evidence-and-ethic informed moral distress intervention informed by the Medical Research Council’s approach to developing a complex intervention.²⁶ The development of the intervention is built on the findings of a scoping review to explore existing moral distress interventions for nurses (Step 1)²⁵ and a qualitative inquiry exploring pediatric critical care nurses’ perspectives on needed elements for a future moral distress intervention (Step 2).³¹ Using a systematic process to develop an intervention maximizes the chance an intervention will be feasible, effective, and sustainable while minimizing resource and research waste.³²

Step 1: Scoping review

To identify and evaluate the evidence on our topic,³³ we conducted a scoping review using the framework outlined by Levac and colleagues,³⁴ and Arksey and O’Malley.³⁵ This review aimed to map out moral distress interventions for nurses providing direct patient care and identify gaps in the existing body of knowledge. Complete details of this review have been detailed in a separate manuscript.²⁵

Step 2: Qualitative description

We used a qualitative description approach³⁶ to conduct in-depth interviews to identify what pediatric critical care nurses who have experienced moral distress identify as needed interventions to minimize moral distress. The details of this qualitative inquiry have been previously reported.³¹

Step 3: Intervention development

Findings from steps one and two and the main tenants of relational ethics were used to inform the final suggested intervention. The Template for Intervention Description and Replication (TIDieR checklist)⁴ was used to guide the description of the intervention components to ensure thorough reporting, transparency, and replicability.

Results

Step 1: Scoping review

Our scoping review revealed that few studies (n = 10) examine moral distress interventions among bedside nurses, and there is no clear pattern as to which strategies consistently minimize moral distress. The three interventions that had a statistically significant reduction in overall moral distress scores included an empowerment program,³⁷ a Freirean-based conscientization intervention directly on moral distress,³⁸ and an educational workshop on moral distress.³⁹ All three of these interventions were focused on a single intervention and had at least two sessions, each lasting either 4 or 6 h. These findings tentatively suggest that longer interventions may decrease moral distress among nurses.²⁵ Additionally, three studies observed a statistically significant decrease in one or more Moral Distress Scale-Revised⁴⁰ survey items but did not note an overall statistically significant reduction in moral distress.^41–43

Step 2: Qualitative description

The findings from our qualitative inquiry identified four broad categories for potential moral distress interventions: increasing support for patients and their families, improving support for nurses, improving patient care communication, and providing education to mitigate moral distress.³¹ These findings indicate that while numerous strategies are in place to help nurses with difficult aspects of their work, further strategies are needed to minimize the negative effects of moral distress.³¹

Step 3: Intervention development

During our qualitative study, both units that participants worked on were richly resourced, with the ability to provide one-to-one patient care, stay up to date with best practice guidelines, and numerous strategies to support nurses in their practice. Yet our findings suggest that despite having these strategies in place, study participants experienced moral distress on multiple occasions. We postulate that this may be because these strategies were not driven by relational practice. The following section will provide a detailed description of the novel moral distress intervention following the Template for Intervention Description and Replication (TIDieR) checklist⁴ and the rationale for these details based on stages one and two of this study and relational ethics (Table 1). The checklist consists of 12 items: brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), and how well (actual).⁴ Utilizing this checklist helps to ensure comprehensive and detailed reporting of the intervention to improve replicability of the intervention.⁴ An additional benefit of using this checklist is to allow stakeholders to implement the intervention as intended.⁴ Developing an intervention is not linear, and refinement of the intervention is to be expected. This intervention should be adjusted in consultation with stakeholders to determine the best fit for the clinical setting and available resources. Once the intervention is finalized for the clinical setting, pilot studies targeting key uncertainties within the design and assessing feasibility should be conducted prior to evaluation.²⁶

Table 1.

Research stage supporting intervention elements following the TIDieR checklist.

TIDieR item	Element supported by relational ethics	Element supported by scoping review (stage 1)	Element supported by qualitative inquiry (stage 2)
1. Brief name	N/A	N/A	N/A
2. Why
• Singular in focus		X
• Communication focused	X	X	X
• Interdisciplinary	X	X	X
• Intervention format		X	X
3. What: Materials	X
4. What: Procedure	X	X	X
5. Who provided		X	X
6. How			X
7. Where	X		X
8. When and how much		X	X
9. Tailoring^a
10. Modifications	N/A^b	N/A^b	N/A^b
11. How well: Planned	N/A^b	N/A^b	N/A^b
12. How well: Actual	N/A^b	N/A^b	N/A^b

^aCells left black as tailoring is based on Bellg et al.⁴⁴ and Craig et al.²⁶

^bNot applicable at this time. Clarity will be sought with future research.

Item 1. Brief name: Relational ethics informed interdisciplinary meeting for moral distress.

Item 2. Why—the rationale, theory, or goal of the elements essential to intervention:

Inclusion of the rationale, theory, or goals that underpin the interdisciplinary meeting helps others to understand which aspects of the intervention are foundational and which are discretionary. Using theory to inform the development of an intervention is more likely to result in an effective intervention than using evidence alone.²⁶ Moral distress is an ethical issue that occurs because of a rupture in a relationship either with ourselves, a patient (including their family), a healthcare team member, or with the environment (e.g., unit structure, organizational structure, and socio-political environment). Relational ethics states that dialogue is where ethical action occurs and where people can come together to ask questions and explore solutions. This ethics also prioritizes the relationships between individuals, and dialogue to foster relationships should be the central focus of a relational ethics-informed moral distress intervention. We used a sequential knowledge development approach to guide the development of this intervention and have detailed our key findings from steps one and two below.

The results from our scoping review (step one) show that only three of the included studies had an overall decrease in moral distress. None of these three studies examined an intervention that focused on proactive communication among team members.²⁵ However, one study included in our review developed a clinical mentoring and ethics support intervention titled Pediatric Ethics and Communication Excellence (PEACE) rounds.⁴³ This intervention focused on interdisciplinary communication regarding ethical and medical aspects of patients with an extended length of stay and was facilitated by a clinical ethicist and the senior intensivist.⁴³ The findings from our review also revealed that interventions with a single focus (e.g., single component vs multiple components) and are longer in duration could help minimize moral distress.²⁵

The findings from our qualitative inquiry (step two) reveal that pediatric critical care nurses identify improving patient care communication as one of many possible outcomes needed to be achieved by an intervention to mitigate moral distress. Participants in our study discuss specific venues for this communication to take place, including interdisciplinary meetings. However, participants strongly purported that a proactive intervention—rather than a reactionary intervention—that allowed room for interprofessional dialogue prior to them experiencing moral distress, and hopefully minimizing future moral distress, was needed. Participants also noted that establishing reliable unit practices (e.g., consistent scheduling of the intervention and a priori criteria of patients discussed) to ensure the intervention is implemented consistently and predictably and that the intervention occurs within a supportive environment is needed.³¹

One of the key features of our intervention, informed by the results of our qualitative inquiry, is that it is proactive, allowing healthcare professionals to discuss current patient cases before the patient’s situation becomes more complex.³¹ Additionally, using relational ethics to guide the discussion is another novel aspect of this intervention. Our findings show that despite having multiple supports for ethical situations, participants described these supports as unhelpful for moral distress.³¹ We argue that this is because none of the strategies use a relational lens.

Item 3. What: The materials used in the intervention:

The description of physical and informational material, which is distinct from procedures, is a critical but often overlooked element. This material includes information given to providers of the intervention during training as well as material given to participants.⁴ Providers of the intervention should be given information about relational ethics to ensure their understanding of the ethic to ensure its fidelity.⁴⁴ The facilitator’s understanding should include recognizing relational ethics is an action ethic that assumes ethical practice occurs within relationships and is pluralistic in nature where there may not be one clear outcome. At the core of this ethic is relationships and to foster relationships open dialogue needs to occur.²⁸ Within these relationships there is mutual respect including respect for differences of opinions, values, and experiences, as well as respect for one’s embodied knowledge. This ethic requires engagement or intentional action to hear what others are saying while also recognizing the influence the environment has on ethical situations.²⁸ It is also essential for the intervention providers to recognize that relational ethics better reflects the complexities in day-to-day ethical situations and can support nurses through morally distressing situations.²⁷ The intervention providers also need to be given and understand the details of the procedures as described in item four below.

The participants should be provided with pertinent medical and social details of each patient’s case. They should also be provided with supports and contact information to relevant resources should they become upset during the intervention. Supports could include meeting with a social worker, psychologist, or manager depending on what is available.

Item 4. What are the procedures and processes used in the intervention:

The intervention procedure should include interdisciplinary discussion around patient-related challenges, room for questions, and exploration of possible solutions. Complex patients (as described below) currently on the unit should be discussed in each meeting. Intervention participants should include those directly caring for a complex patient. The facilitator should start by presenting pertinent details of the patient’s case via an oral presentation and then guide participants in a discussion exploring any questions and possible solutions related to patient care. This discussion could be guided by the Relational Ethics Decision-Making Framework (Table 2).⁴⁵ This framework lists four key questions with numerous sub-questions under each section. The key questions include “What is happening here?” “What are the alternatives for ethical action?” “What is the most fitting thing to do?” and “What happened as the result of our action?” (p.110).⁴⁵ Once the discussion about a patient is complete, the facilitator should discuss the next patient’s case. This process may need to be adjusted in consultation with stakeholders and after pilot testing the intervention. Once finalized, the procedure should be preserved and well-defined to reduce unintended variability of the intervention and improve fidelity.⁴⁴

Table 2.

A relational ethics decision-making framework.

Key Questions

1. What is happening here?

2. What are the alternatives for ethical action?

3. What is the most fitting thing to do?

4. What happened as the result of our action?

Question 1: What is happening here?

• What are the ethical questions? Their context?

• Who is involved? (Who are the moral agents?) What are their commitments to one another?

• What further information do we need?

• Are there legal, organizational, professional, cultural, religious, or any other aspects to consider? Are values in conflict?

• What resources do we have? Need?

• Patient and family resources (e.g., personal directives)?

• Health care resources: (e.g., access to home care)?

• Ethics resources: Principles, precedents, codes, policies, guidelines, ethicists/ethics committees, etc.?

• To what, in particular do we need to attend?

Question 2: What are the alternatives for ethical action?

• What are the consequences for each alternative?

• What might constrain ethical action? What, if anything, makes me or others uncomfortable in regard to a potential action?

• Remember: Refraining from making a decision is still a decision.

Question 3: What is the most fitting thing to do?

• What is the best way to carry out the decision (or plan)?

• Who is affected? Who needs to be involved?

• How many disparate views be bridged?

Take action

Question 4: What happened as the result of our action?

• What concerns remain?

• Is anyone distressed about the result?

• Is further action desirable?

• Do we need to address systemic factors that gave rise to the situation?

• Would we act in the same way again?

• What did we learn?

The results of our qualitative study demonstrate that patients should be discussed in the intervention based on specific criteria that could indicate a more complicated plan of care for the patient (diagnosis, length of stay, or family situations), thus increasing the potential for a morally distressing situation. Participants also suggested having a standardized process to increase the opportunity to discuss potential challenges and ensure that the intervention is implemented in a consistent and predictable manner. Having a standardized approach is not meant to be prescriptive; instead, it is suggested to reduce power dynamics among team members and encourage open dialogue about all aspects of care.³¹ Similarly, Wocial and colleagues’⁴³ intervention focused on patients with an extended length of stay and communication about challenging medical and ethical aspects of patient care as well as the rationale for treatment interventions if applicable.

Item 5. Expertise, background of the intervention provider:

We recommend that the intervention should be led by someone trained in facilitating communication (such as a social worker, ethicist, or psychologist). This level of training (e.g., degree in which communication and relationships were a primary focus) was reported as a required element based on the data from our qualitative study.³¹ It is essential to have the same facilitator throughout the intervention to maintain and reinforce standards.⁴⁴ The intervention by Wocial and colleagues⁴³ was led by a senior intensivist to help focus the discussion on treatment goals and an ethicist to facilitate discussion surrounding potential ethical conflict. We recommend that the attending physician is present for each session to provide pertinent details of each patient’s clinical status as needed.³¹

Item 6. How:

The delivery method of the intervention should be face-to-face meetings. Relational ethics recognizes the ethical space as a necessary component to foster relationships and understand ethical action. This space is where people come together to connect and understand each other through dialogue as well as through unspoken communication,^28,29 and this connection is best cultivated when sharing the same physical space. However, participants in step two mentioned that zoom meetings are helpful to accommodate busy schedules and encouraged them to attend meetings when they were not on the unit.³¹ We recommend that each unit explores its organizational privacy and confidentiality policies before including virtual or hybrid options.

Item 7. Where:

The interdisciplinary meetings must occur in a safe and welcoming space, free from the power structures that are often found within healthcare.³¹ This safe space refers to both the physical space and the situational space. The physical space should be large enough to fit everyone comfortably and somewhere secluded to promote confidentiality. Using a relational ethics lens, the environment is a living, ever-changing system that connects us all.⁴⁴ It is interdependent, and ethics (including moral distress) cannot be understood by looking at an individual or even a single situation. Instead, we need to examine how the people within the environment interact with one another and create a space for ethical reflection to occur.²⁸ Relational ethics asks, “could this environment change if attention to the relationship was our primary ethical commitment?” (p. 167).²⁸ For the intervention to flourish, where all participants can contribute, the immediate environment surrounding the intervention needs to occur in a safe space. Creating a safe space starts with mutual respect, respecting ourselves and the others involved in the situation. Respect includes respecting the knowledge, opinions, values, beliefs, and experiences of everyone involved. It also includes respecting differences in power (that are often inherent within the healthcare system) and uses of this power. It is also imperative to respect the embodied knowledge of others because factual knowledge is not enough.

Respect of emotions and feelings is needed during the intervention. Distress is experienced within one’s body, and to minimize this distress we need to respect its bodily manifestations and recognize these manifestations as knowledge about the situation that causes distress. This space also requires engagement to move beyond a technical relationship with data and monitors and attempts to look at a situation together. Without engagement, the healthcare team can sit in a room together, yet the individuals can feel completely alone and unheard. Engagement, therefore, is necessary to move toward one another and find an ethical solution. This environment can be created by fostering a sense of community and encouraging open communication that is respected among all participants. Findings from stage two show that having a neutral facilitator to decrease power differentials and establishing reliable unit practices to promote intervention consistency and predictability could help foster a safe environment.³¹

8. When and How much:

We recommend 60-min weekly meetings^46–48 but recognize that this may not be feasible for all settings. This would provide sufficient time for multiple voices to be heard and could be adjusted as needed. Meetings with key stakeholders such as the healthcare team, managers, and policymakers are necessary to determine the frequency of the intervention, how it could fit within everyday practice, and explore potential barriers.²⁶ Wocial and colleagues held weekly meetings for 1 year. Participants from our qualitative inquiry suggested weekly, proactive meetings to discuss complex patients before potentially distressing situations occur and as they evolve (shortly after admission, before surgeries or procedures, changes in goals of care, etc.).³¹

9. Tailoring:

The MRC complex intervention framework highlights that intervention should be tailored based on the clinical setting and available resources.²⁶ Tailoring may include the frequency and length of each session, who should attend (e.g., attending physician, resident, and fellow), which patients are discussed, and determining how to best support staff to attend (e.g., virtual options and arranging coverage). However, to ensure fidelity some aspects should not be changed⁴⁴ including the materials provided to the intervention facilitators, the procedures, and where the intervention occurs (the safe space).

Items 10. Modifications and 11. and 12: How well:

These items are not applicable at this time but will need to be reported once the intervention is finalized, tested, and evaluated.

Discussion

This paper illustrates the multi-phase, evidence-and-ethics-informed [ensure conistent in title and in text] strategy undertaken to develop a novel moral distress intervention for pediatric critical care nurses. This intervention builds on two previous phases couched with a relational ethics lens: a rigorous scoping review to identify moral distress interventions and gaps in the research, and a qualitative inquiry to understand what pediatric critical care nurses identify as needed interventions to minimize moral distress. We have organized the discussion to explore (a) moral distress interventions to increase communication and (b) alternative theory-driven moral distress interventions.

We propose proactive, interdisciplinary meetings informed by relational ethics as one possible strategy to minimize the negative effects of moral distress. Recent research has shown that increasing communication among the interdisciplinary team may effectively reduce moral distress.^43,49,50 Data from our qualitative study describes the importance of improving patient care communication among the disciplinary team.³¹ This study emphasizes the need for a proactive moral distress intervention that occurs before a patient situation becomes complicated.

These findings are in tension with recent moral distress interventional studies. A few studies have implemented interventions to increase patient care communication; however, these studies are often in the form of debriefing sessions. By virtue of a debriefing method, these interventions are implemented after a morally distressing situation has occurred. Vacklavik et al.⁴² developed a mindfulness bundle that included clinical debriefing sessions after a significant event. While they did not find an overall reduction in Moral Distress Scale-Revised scores, they found a significant reduction in one survey item corresponding to moral distress frequency. In Browning and Cruz’s⁴⁹ study examining the effects of a social work-led reflective debriefing intervention, participants reported benefit from discussing situations with colleagues, receiving recognition related to their nursing concerns, and having the opportunity to discuss their emotions. Fontenot and White⁵¹ conducted a pilot study examining the effects of debriefing following the American Association of Critical Care Nurses model “The 4A’s to Rise Above Moral Distress.”⁵² The researchers found no significant reduction in moral distress pre-intervention compared to post-intervention. However, participants reported subjective benefits by increasing their awareness of moral distress, providing them time to talk with colleagues, and encouraging them to improve their self-care habits.⁵¹ Morley and Horsburgh⁵⁰ describe their five-phase Moral Distress Reflective Debriefing intervention as one designed to respond to morally distressing patient situations. They discuss the importance of a clinical ethicist as a facilitator for this intervention and how this intervention compliments ethics consultation. Although they do not report any empirical data, the researchers demonstrate, through two case studies, that this approach shows promise in minimizing moral distress.

Alternatively, Wocial et al.,⁴³ as discussed in detail throughout our findings, developed a proactive interdisciplinary ethics rounds intervention. This intervention did not reduce overall moral distress when comparing pre-test to post-test Moral Distress Scale-Revised scores. However, this intervention had a statistically significant reduction in three scale items and statistically significant positive effects on patient outcomes, including a change in code status and length of stay.⁴³ Developing a proactive intervention may effectively minimize moral distress by allowing the healthcare team to come together to discuss the situation, seek clarity, share their feelings, and possibly feel validated.

To our knowledge, no researchers have been guided by relational ethics to shape the development of a moral distress intervention. Several interventional studies for moral distress are atheoretical yet as demonstrated in our scoping review a few have implemented interventions using a variety of theories, lens, or perspectives to varying degrees.²⁵ The Medical Research Council states that using a relevant theory in the development of an intervention can increase the likelihood the intervention will be effective than using evidence alone.²⁶ Abbasi and colleagues³⁷ used a moral distress theory as the foundation to guide the development of their intervention. Nathaniel’s Theory of Moral Reckoning in Nursing⁵³ was developed to understand moral distress and is based on the premise that nurses experience moral distress because of irreconcilable conflict between their values and external forces.⁵³ One limitation of this theory is that it is broad and therefore only touches on its key elements superficially. Additionally, this theory does not suggest that it could inform strategies to develop interventions⁵³ and its suitability for this application is questionable.⁵⁴ Abbasi and colleagues³⁷ use this theory to guide the application of their empowerment intervention and resulted in an overall statistically significant decrease in moral distress among participants.³⁷

Other theories researchers used to guide intervention development include nursing theories as well as theories from a variety of disciplines. Meziani et al.⁵⁵ utilized two nursing theories in their reflective practice interventional study, including Watson’s Concept of Human Caring⁵⁶ and Johns’ model for structured reflection.⁵⁷ Watson’s Concept of Human Caring is a nursing theory that aims to elucidate the human caring process.⁵⁶ John’s model outlines what being a reflective practitioner involves and how nurses can engage in reflective practice.⁵⁷ Johns’ model for structured reflection guided the development of the reflective practice intervention, and it is unclear the extent Watson’s model was utilized. Disappointingly, the results of this intervention did not show a statistically significant difference in pre- and post-intervention moral distress.⁵⁵

Bevan and colleagues⁵⁸ used Freire’s pedagogy of the oppressed⁵⁹ to guide the aims, development, and delivery of their conscientization curriculum intervention. This educational theory aims to use everyday experiences to raise the consciousness of an oppressed group to increase their collective power and bring about change.⁵⁹ The findings from this study show an overall decrease in moral distress.⁵⁸

Lastly, we found two studies that used models to inform the development of their intervention. Browning and Cruz⁴⁹ used several elements of the 3D Model of Debriefing, based on adult learning theory, as the structure for their reflective debriefing intervention. This model aims to help debriefers facilitate learning to improve practice and focuses on defusing, discovering, and deepening the goals of debriefing.⁶⁰ This intervention shows that participants reported benefit from the debriefing sessions.⁴⁹ Vaclavik and colleagues⁴² used the key elements of Felgen’s change model⁶¹ to guide the development of their multipronged mindfulness intervention. This model demonstrates the fundamental aspects of a successful, large-scale change.⁶¹ This study shows a significant decrease in one Moral Distress Scale-Revised survey item.⁴² Some of the interventional studies guided by theories, lenses, or perspectives as described above show promising results. However, none of these studies use an ethical lens to develop their intervention. Therefore, relational ethics provides a novel and valuable perspective to guide the development of a moral distress intervention, given the ethical nature of the phenomenon. The development of the current intervention is built on the findings from a scoping review exploring existing moral distress interventions for nurses (step 1)²⁵ as well as a qualitative inquiry exploring pediatric critical care nurses’ perspectives on needed moral distress interventions.³¹ While the aim of the intervention is to minimize moral distress among pediatric critical care nurses, the scoping review was not limited to this population. Therefore, the intervention may be transferable to other critical care areas and should be tailored based on the unit’s needs and resources.

Conclusion

Based on the results of our multi-phase research, we propose a relational ethics-informed proactive interdisciplinary meeting as one possible moral distress intervention. Moral distress is a complex ethical experience that occurs when one cannot act in a way that aligns with what they feel is the ethically correct action. This distress occurs due to a break in a relationship, and interventions to minimize the negative effects of moral distress are desperately needed. Relational ethics prioritizes relationships in ethical situations and aligns well with moral distress’ complex, ethical, and pluralistic nature. Therefore, this ethic can further our understanding of moral distress and potentially minimize its devastating impact on nurses, patients, and the healthcare system.²⁷ Future studies are needed to finalize this evidence-and-ethic informed intervention in partnership with key stakeholders to determine feasibility within everyday practice and explore barriers to implementing the intervention.²⁶ Once finalized, the intervention will be pilot tested to assess its efficacy. Our evidence-and-ethic informed intervention offers a novel approach to address moral distress and has the potential to better support pediatric critical care nurses experiencing the phenomenon.

Footnotes

Author contributions

All authors named have contributed substantially to drafting the manuscript and have approved the final version to be submitted. All those entitled to authorship are listed as an author. This manuscript has not been published and is not under consideration for publication in another journal.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

ORCID iD

Sadie Deschenes

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