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Debriefing and Reflective Interventions to Address Moral Distress: A Narrative Review

Danielle Moverley, BScN, RN, Tanya Park, PhD, RN and Carmel Montgomery, PhD, RN

Abstract

Moral distress is a common phenomenon found in all areas of nursing practice with a high prevalence in specialties such as critical care nursing. The under management of moral distress is associated with the development of burnout, issues with nursing turnover, and patient safety concerns. Identification of effective interventions to address moral distress remains a novel topic of investigation. The aim of this project was to explore the use of debriefings and reflective practices to address and alleviate moral distress. The population of interest included nurses working in all acute care areas including adult and pediatric populations, with a focus on critical care. A narrative literature review was completed using a combination of both quantitative and qualitative studies. Database searches were conducted on both MEDLINE and CINAHL. A total of 10 studies were included in the review. The majority of the studies utilized interventions with both an educational and reflective or debriefing component. A variety of approaches were used in relation to intervention implementation including timing, the profession of both the participants and facilitators, moral distress measurement instrument, and intervention duration and frequency. Most of the studies did not find a significant change in moral distress levels or severity between pre-and post-implementation of the moral distress intervention. No longitudinal studies were conducted to assess the long-term implementation of programs or moral distress measurements. Given the high prevalence and cost of moral distress in the nursing profession more investigation into interventions is required.

Implications for nursing

Moral distress is a common phenomenon found in all areas of nursing practice with a high prevalence among critical care nurses. Identification of effective interventions to address moral distress is a priority need in critical care nursing practice across Canada. Further study is needed to address the challenges of implementing moral distress programs in the intensive care unit (ICU) setting.

Keywords: moral distress, critical care nursing, intensive care unit, emotional exhaustion, debriefing, moral distress interventions

Moral distress has been defined as the product of the health care professional’s inability to follow the ethically deemed appropriate action despite having awareness of the morally correct choice (Jameton, 1993). This inability can be due to several external barriers such as time constraints, institutional policies, power hierarchies or legal constraints (Mobley et al., 2007). Value conflicts and team dynamics contribute to internal barriers (Corley, 2002). Moral distress can elicit emotional, physical and social consequences, with lasting effects both personally and professionally (Mobley et al., 2007; Langley et al., 2015).

Moral distress has been studied in a variety of health care settings, with clear research evidence of its occurrence in critical care areas, such as the intensive care unit (ICU) (Mealer & Moss, 2016; Mobley et al., 2007). Critical care nurses are at risk for moral distress related to repeated ethical conflicts associated with advances in medical technology, high-stress work environments, and frequent exposure to end-of-life situations (McAndrew et al., 2018). Moral distress is highly prevalent in critical care nurses with reported incidence as high as 80% in some studies (Corley, 2002; Mealer & Moss, 2016). Nurses have higher rates, in comparison to other health care professionals, due to their integral role in patient care, perceived lack of power and feelings of voicelessness in ethically complex scenarios (Mealer & Moss, 2016).

The COVID-19 pandemic, declared in March 2020, led to an overwhelmed health care system with an increased number of critically ill patients (Petrisor et al., 2021). The pandemic also added personal and professional psychological burden on health care professionals with exposure to increased workloads, reduced resources and high incidence of patient mortality (Petrisor et al., 2021). The frequency and duration of exposure to precipitants contribute to ICU nurses being susceptible to moral distress and its lasting consequences. The pandemic has prompted greater research on moral distress (Petrisor et al., 2021). This will help gain understanding of the impact of moral distress in critical care nurses, its precipitants, outcomes and possible solutions (Petrisor et al., 2021).

Consequences of Moral Distress

The negative implications of moral distress can have lasting impacts on the well-being of the nurse, patient, and the nursing profession. If left unidentified or untreated, moral distress can lead to emotional, bodily and social consequences for the individual nurse (Forozeiya et al., 2019). Feelings of stress, frustration, anxiety, insomnia, and withdrawal from social interactions are a few of the personal impacts that can be experienced due to moral distress (Forozeiya et al., 2019).

There is both an acute and a chronic component to moral distress (Epstein & Hamric, 2009; Rushton, 2016). Acute levels of moral distress can be experienced via the body’s stress response to ethically challenging scenarios (Rushton, 2016). Over time, unprocessed moral distress can accumulate and create a lingering crescendo effect, called moral residue (Epstein & Hamric, 2009; Rushton, 2016).

It has been argued that critical care nurses primarily use evasive coping strategies and avoidance of the distressing issue altogether (Forozeiya et al., 2019). This can lead to nurses becoming increasingly withdrawn and disengaged from their practice (Forozeiya et al., 2019). These changes to their practice can have negative impacts on nursing care and elicit decreased patient/family support, higher frequency of medication errors and reduced patient advocacy (Henrich et al., 2017).

Negative effects are also seen in job attrition and turnover rates in the nursing profession. Dodek et al. (2016) found 52% of ICU nurses responding to a survey (n=428) in British Columbia indicated they had considered leaving or had left their job in the past due to moral distress. An Ontario provincial report on critical care services identified the overall provincial nursing turnover rate was 10% and a vacancy rate of 5.4% in critical care units (Critical Care Services Ontario, 2019). There has been a recognized nursing shortage for many years in Canada, which has been heavily emphasized by increased demands on the health care system during the COVID-19 pandemic (Canadian Nurses Association, 2021).

Moral Distress Interventions

There has been an abundance of research conducted on the existence of moral distress in both critical care nursing and health care in general (Browning & Cruz, 2018). However, the implementation and evaluation of interventions to address moral distress are emerging topics of interest (Browning & Cruz, 2018). There is a growing body of literature related to the use of debriefings as a method to mitigate the negative effects of moral distress for health care professionals. However, there has not been a formalized approach to how these services are provided (Hamric & Epstein, 2017). A multitude of models have been used to frame debriefing sessions including the 3D (i.e., debriefing, defusing, discovering) model of debriefing, American Association of Critical Care Nurses (AACN) 4As (i.e., ask, affirm, assess, and act) of moral distress, and models of structured reflection (Fontenot & White, 2019; Mezaine et al., 2018; Savel & Munro, 2015; Zigmont et al., 2011). The majority of debriefing sessions include both a reflective and educational component to increase program participant knowledge of moral distress and effective coping strategies (Mezaine et al., 2018).

The Measurement of Moral Distress

The predominant tool used to measure moral distress is the moral distress scale (MDS) introduced by Corley in 2001 (Tian et al., 2021). This was the first instrument developed to measure both the frequency and severity of moral distress in ICU nurses (Tian et al., 2021). The revised version of this tool, the MDS-R, was first introduced in 2005 and extensively validated (Tian et al., 2021). There are currently six versions of this instrument designed for various health care providers and patient populations (Tian et al., 2021). The MDS and MDS-R use a 7-point Likert scale to measure moral distress disturbances related to patient care situations. These scales produce numerical scores to represent both frequency and severity of moral distress and are combined to make a composite moral distress score. The higher the moral distress score, the greater the level of moral distress (Tian et al., 2021). There are a number of other moral distress measurement instruments used in clinical practice and research. These include the measure of moral distress for healthcare professionals (MMD-HP) by Epstein et al. (2019), the moral distress thermometer, and other revised versions of the MDS-R (Hamric et al., 2012; Wocial & Weaver, 2012). However, they all fail to exhibit the extensive validity and reliability that the MDS and MDS-R present (Tian et al., 2021). These tools provide a quantitative measure to illustrate moral distress presence and severity, and demonstrate the effectiveness of moral distress interventions.

Purpose

A narrative literature review was completed to summarize the findings on the use of debriefing and reflective programs to manage moral distress (Ferrari, 2015; Frederiksen & Phelps, 2020). A narrative literature review provides an “overview of research on a particular topic that critiques and summarizes a body of literature” (Frederikson & Phelps, 2020). The narrative review also entails an analysis and discussion of methodologies, findings, limitations, and areas for future development (Frederikson & Phelps, 2020). The aim of this project was to explore the use of debriefings and reflective practices to address and alleviate moral distress. Debriefings included programs delivered in both group and individual settings. The narrative literature review process allowed for a comprehensive summary of existing literature on this subject and the ability to identify gaps for future areas of study (Frederiksen & Phelps, 2020). Due to the narrative literature review method, a rigorous evaluation of the individual study quality of the chosen articles was not completed. The narrative review process is at risk for introducing a subjective analysis, but clear selection and exclusion criteria were used to minimize bias (Frederiksen & Phelps, 2020). Additionally, barriers and facilitators to program implementation were evaluated to gain understanding of how to implement successful debriefing and reflective practice programs.

Methods

Qualitative, quantitative, and mixed-method studies were included in the review. Database searches were conducted in both MEDLINE and CINAHL from January 2010 to January 2022 to ensure information gathered was relevant to current practice. Search terms included (“moral distress” or “moral stress” or “ethical distress” or “ethical stress” or “moral dilemma” or “ethical dilemma”) and (educat* or workshop* or teaching or learning or debrief* or “de-brief” or reflection* or train*) and nurs* and (“acute care” or “critical care” or “intensive care” or ICU or emergency or “trauma cent*”). The focus was on nurses, with studies involving nursing students alone excluded from the search.

All articles were read by the primary author and were assessed for pre-determined inclusion and exclusion criteria (Table 1). Critical care nurses were the primary population of interest, but other acute care nurses were included to capture interventions that may be transferable to the ICU (Epstein et al., 2019). Adult and pediatric populations were included due to the ubiquitous nature of moral distress and use of similar interventions across age groups (Epstein et al., 2019).

Results and Discussion

Studies were reviewed and selected in a systematic manner beginning with title and abstract screening, followed by full-text reviews. Results of the screening process are summarized in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (Page et al., 2021) (Figure 1).

The initial search identified 364 studies; 113 duplicates were removed at this primary stage. Abstracts and titles were then screened, and 212 studies did not meet the inclusion criteria. Full-text reviews were completed on 39 articles. At this stage, a further 29 articles were excluded because they were published editorials, letters, or did not meet inclusion criteria of having implemented interventions or measures of moral distress.

The studies included in the review used a variety of study designs: seven quantitative designs, two qualitative designs, and one mixed methods. The studies were conducted in a number of countries including seven studies from the United States, two from Iran, and one from Canada (Table 2). A summary of the chosen studies and their characteristics (i.e., setting, moral distress instrument, intervention, outcome, facilitators, and barriers) are outlined in Table 2. 

Content analysis was performed by systematically reading each study and identifying and analyzing the instrument used to measure moral distress, the components of the intervention, outcomes of the study, and identified barriers and facilitators of the interventions. A conventional approach to content analysis was performed, where the chosen studies were read as a whole, and common themes/categories were derived from them (Hsieh & Shannon, 2005). These categories were then utilized to build the summary of included studies (Table 2) and analysis of these categories between the various research studies was outlined in the discussion. 

Components of the Intervention

The studies captured a variety of details related to the programs including the intervention, length and frequency of sessions, profession of facilitators, and staff included in the program. Most of the programs included educational and reflective components to allow staff to learn about moral distress, increase their self-awareness of moral distress and discover effective coping strategies. Additionally, through reflective practices staff could develop an understanding of how to apply these skills in clinical scenarios and practice. Most of the studies included real-life morally distressing situations experienced in the workplace, either provided by the nursing staff themselves or unit leadership. Rushton et al. (2021) included simulation scenarios and role playing to help further grow these skills through repeated practice and discussion. None of the studies compared the difference in moral distress levels with the utilization of hypothetical clinical scenarios versus real-life scenarios during the debriefing sessions. The research approaches used either real-life or hypothetical scenarios in isolation from each other. This would be an interesting area for future research to determine if the use of one approach has more impact on moral distress. Other programs included narrative writing (Saeedi et al., 2018) and interdisciplinary care plan discussions (Wocial et al., 2017). These may be useful adjunct interventions and need further study in combination with moral distress education programs to determine if they contribute to long-term reductions in moral distress.

Interventions varied between intensive isolated workshops studied by Abbasi et al. (2018) to more frequent weekly or monthly sessions studied by Browning and Cruz (2018), Chiafery et al. (2018), Fontenot & White (2019), Leggett et al. (2013), and Mezaine et al. (2018). To enhance the program’s impact a combined approach may be useful, including both intensive initial workshops and long-term shorter sessions. The initial intensive workshops would provide a knowledge base and improved understanding of moral distress while long-term, shorter sessions would address the chronic aspects of moral distress (i.e., the moral residue). However, further research is needed to determine the optimal frequency and duration of programs.

Moral Distress Instrument

Six of the studies applied the Corley MDS-R which measured both the intensity and frequency of moral distress (Tian et al., 2021). However, a variety of other quantitative and qualitative instruments were used simultaneously in the studies, including the moral distress thermometer (Chiafery et al., 2018). The moral distress thermometer measures the presence of moral distress in an acute period, within the previous two weeks, and provides a rapid measurement of current levels of moral distress (Wocial & Weaver, 2012). Therefore, it may be useful in screening for moral distress and trending repeated measures of moral distress over time in response to interventions.

Rushton et al. (2021) used a number of collateral instruments to measure downstream impacts of moral distress such as work engagement, mindful attention, emotional empathy, and perceived ethical confidence scale. Although these scales do not specifically measure for moral distress, they provide insight into the incidence of moral distress complications and correlational relationships. Reilly and Jurchak (2017) evaluated focus group responses about perceived levels of moral distress, degree of moral distress knowledge, and coping strategies in a qualitative study.

The majority of the studies did not find a significant change in levels of moral distress following program implementation (Abbasi et al., 2018; Browning & Cruz, 2018; Fontenot & White, 2019; Mezaine et al., 2018; Rushton et al., 2021; Saeedi et al., 2018). Results were similar across all moral distress instruments. All studies measured moral distress in an acute time period ranging from 6 weeks to 9 months following short-term implementation of programs. No longitudinal studies were completed to determine the intervention’s long-term impact on moral distress. This is a key limitation as nurses may require time following the interventions to translate their new moral distress knowledge into routine practice. Although these studies may fail to show a decline in moral distress levels, results of the intervention’s true impact may have shown different results if measured after a longer timeframe.

Three studies identified a significant decline in the moral distress scores when comparing pre-and post-intervention measures (Chiafery et al., 2018; Leggett et al., 2013; Wocial et al., 2017). Some reasons these authors hypothesize that led to a significant decline include small sample sizes, significant outliers in their sampling, and the acute time of their measurements post-debriefings. However, further analysis will have to be conducted to thoroughly support or dispute these reasonings as to their significant findings versus the multitude of others with nonsignificant results.  

Barriers and Facilitators to Program Implementation

Barriers

The studies included in this review highlight several obstacles to implementing an effective program to deal with moral distress. The most common barrier experienced was ensuring program participation and scheduling of the intervention. The majority of nursing in acute care areas encompass both day and night shifts and finding an appropriate time that is ideal for both groups is challenging. Fontenot and White (2019) found that hosting the program near shift change allowed staff from both day and night shifts the opportunity to attend. Another challenge is ensuring patient care on the unit is adequately managed and that the program is provided at an optimal time aligned with a lighter workload on the unit.

The majority of the studies assessed programs provided only to nurses. It is well studied that the nursing profession holds the highest incidence rates of moral distress and thus is the greatest in need of moral distress interventions (Mobley et al., 2007). However, major challenges discussed included interdisciplinary team relationships and communication (Mezaine et al., 2018; Wocial et al., 2017). Incorporating a component of interdisciplinary participation in the programs may foster improved collaboration and a supportive work culture, thus minimizing nurses’ feelings of voicelessness, powerlessness, and frequency of morally distressing situations. The programs can be both financially and time-consuming to build and implement into a workplace (Rushton et al., 2021). Support and participation must be facilitated by healthcare leadership to aid in the effective implementation of these vital supports to ultimately encourage change.

Facilitators

There were a number of positive attributes identified from the various interventions implemented in the studies. Browning and Cruz (2018) identified that monthly frequency for debriefing and education sessions was most effective. However, they did not assess if the services should be provided for a finite period or indefinitely. Abbasi et al. (2018) found that providing briefings following educational workshops was helpful to ensure knowledge retention and proactively address questions that may have arisen.

Chiafery et al. (2018) and Leggett et al. (2013) showed that a combined individual and group approach to debriefing is the most beneficial to promote participation and decrease moral distress levels. Providing an individual component ensures that participants who may be uncomfortable participating in a group environment are still offered an opportunity to reflect and debrief. Also, individualized debriefing services can be provided to those who may be outliers experiencing higher moral distress than their coworkers and are at higher risk for moral distress downstream complications. Moreover, Mezaine et al. (2018) found that limiting the group size to a maximum of 10 participants allowed for effective group discussion and debriefing.

Reilly and Jurchak (2017) identified that the skill of the program facilitator is important to the program’s effectiveness. Nurse ethicists and social workers have specialized education and training in debriefing situations contributing to moral distress and are a great resource for intervention programs (Browning & Cruz, 2018; Reilly & Jurchak, 2017). Their professional background and expertise equip them to provide structure, guidance, and direction to debriefing discussions and ensure session goals are achieved (Reilly & Jurchak, 2017).

Attendance of clinical leaders at the debriefings was seen as a positive asset and provided further support for nursing staff to openly reflect and debrief (Reilly & Jurchak, 2017). Attendance also provided leadership the opportunity to learn about workplace issues that may not otherwise be evident to them (Chiafery et al., 2018). The presence of leadership at the debriefings also helps mobilize change strategies identified at the sessions and promotes a supportive work environment.

Further Research

The findings of this study outline promising interventions to address the growing burden of moral distress among nurses (Browning & Cruz, 2018). Investigation into potential strategies to prevent and mitigate moral distress is a novel topic (Browning & Cruz, 2018). The minimal existing literature in this area shows varied results and the need for future attention to effectively evaluate the impact of moral distress interventions (Dacar et al., 2019; McAndrew et al., 2018; Morley et al., 2021).   

As previously mentioned, all current literature on moral distress interventions assesses their effectiveness on an acute timeline. Longitudinal studies are required to effectively assess the intervention’s impact on moral distress levels, and it remains unknown what the best timeline is for follow-up measurement.

Another area of potential research is the assessment of workshop effectiveness versus long-term interventional supports. One of the largest barriers to providing supportive programs is the scheduling and availability of staff due to shift scheduling constraints. Therefore, an intensive 2 to 3-day workshop may be beneficial to overcome this dilemma. However, the efficacy of this approach versus long-term intermittent programming needs to be assessed.

The studies in the review used a variety of frameworks to build their programs and supports. Further work is required to assess the impact of these models and determine an influential program to address moral distress. The majority of the programs studied addressed debriefing of morally distressing clinical situations. However, the COVID-19 pandemic has introduced a new array of moral distress triggers in the ICU, including an increase in the volume of dying patients, visitor restrictions, increased workloads and staffing shortages, vaccine hesitancy, concern for personal safety, and the use of novel treatments and interventions (Godshall, 2021). These topics require exploration regarding their contribution to moral distress and further highlight the urgent need for the development and implementation of moral distress interventions.

Conclusion

Moral distress is a highly prevalent phenomenon in health care professionals, with ICU nurses being most susceptible. While there is a wealth of research and knowledge on the presence, triggers, and downstream complications of moral distress, few studies have focused on interventions. The novel studies focusing on assessing supports for moral distress use a variety of approaches to program implementation. However, they all largely include an educational and reflective component to the program. Most of the studies were unable to show a significant change in moral distress severity and frequency following program implementation, although, all studies were limited to evaluating program implementation and moral distress measurement on a short-term timeline. Further longitudinal studies are required to effectively assess program impact on acute and chronic moral distress. Additional work is required to address the challenges of implementing moral distress programs in the ICU setting and providing vital support to ICU nurses.

Table 1.

 Inclusion and Exclusion Criteria

 Inclusion CriteriaExclusion Criteria
 Written in English languageWritten language other than English
 International sourcesEditorials, comments and letters
 Peer-reviewed publicationsPapers published prior to 2010
   
 All study designs (quantitative, qualitative, mixed methods)No clear measure of moral distress or intervention evaluation parameters are reported
   
 Debriefing and reflective interventions targeting moral distress in nurses working in critical and acute care. 
   
 Adult and pediatric ICU staff and physicians 
   
 Papers published January 2010 to January 2021 

Table 2.

Summary of Included Studies

Author and YearSettingMoral Distress InstrumentInterventionOutcomeIntervention Barriers and Facilitators
Abbasi et al. (2018)Medical/surgical adult ICU in IranMoral distress scale revised (MDS-R)2-day workshop hosted for 6 hours per day. Education on definition of moral distress, symptoms, adverse consequences, and strategies to overcome moral distress. Also, it provided reflective group discussion on morally distressing experiences.No significant change in moral distress score at 2 weeks post-intervention. Moral distress score significantly decreased at 1-month post-intervention.Facilitators: Providing a longer and more comprehensive education on moral distress, not just providing ethics training. Providing follow-up briefings after completion of the workshop. Barriers: Cultural barriers between health care professionals, including physician dominance.
Browning & Cruz (2018)Medical/surgical adult ICU in the United StatesMDS-RReflective debriefings and educational workshops on moral distress, moral efficacy and common end-of-life issues experienced in the ICU. Held monthly for 6 months and facilitated by a social worker.No significant change between MDS-R pre-and post-intervention. Non-significant decline in MDS-R scores between experimental and control group. Number of sessions negatively correlated with nurses’ desire to leave position.Facilitators: The monthly frequency of hosting the intervention was found most effective. Barriers: Largest hurdle to attending sessions was timing due to shift work. Need to incorporate the interdisciplinary health care team to ultimately improve and support interdisciplinary culture on the unit.
Chiafery et al. (2018)Adult burn-trauma ICU, adult mixed surgical ICU, and adult medical ICU in the United StatesMoral distress thermometer (MDT)Nursing ethics huddles; small group meetings hosted by a nurse ethicist. Discussion was facilitated around reflection, ethical principles surrounding ethically troubling cases chosen by the nurses.Significant decrease in pre- and post-intervention MDT scores. 68% of the nurses reported a decrease in moral distress after participation in a huddle. Nurses’ perspectives changed on the ethically challenging situation as a result of the discussion. The majority of the nurses reported improvement in patient advocacy skills.Facilitators: Offering extra individual time for debriefing time on a volunteer basis. When leadership is present, it provides them an opportunity to learn about issues that otherwise would not be vocalized. Barriers: Requires flexible scheduling of sessions. During a number of sessions staff were pulled away for patient care.
Fontenot & White (2019)Adult medical ICU in the United StatesMDTDebriefing sessions designed based on AACN’s 4A’s of moral distress. Sessions were moderated by a social worker trained in group therapy and moral distress. Held for 30 minutes 4 times over 10 weeks.No significant difference between mean pre- and post-intervention MDT scores. No relationship found between the number of sessions and post-intervention MDT scores. A temporary increase in nurses’ MDT scores. Nurses reported sessions increased self-awareness, connection with colleagues and fostering self-care habits.Facilitators: Hosting sessions near shift change allowed both day and night shift staff the opportunity to attend. Barriers: Attendance at debriefing sessions was small due to patient care commitments and shift work.
Leggett et al. (2013)Adult burn ICU in the United StatesMDS-R and self-efficacy scaleEducation sessions on moral distress and strategies to cope with moral distress. One 60-minute session hosted each week for 4 weeks. Facilitated by nurse researcher.Significant decrease in the median MDS-R scores between the pre-and post-intervention scores. No significant difference when retested at 6 weeks post-intervention. No significant difference between median pre- and post-intervention self efficacy score.Facilitators: The nurses found it beneficial to have both an individual and group-based component. The length of 60 minutes was deemed most appropriate to enable discussion and learning. Nurses found helpful when combined with other programs as a proactive and ongoing approach to moral distress interventions. Barriers: Timing of sessions to accommodate both day and night shift staff.
Mezaine et al. (2018)Acute care medical/surgical unit in Canada, providing end-of-life care.MDS-RReflective and educational sessions lasting between 45-75 minutes given every 2-3 weeks. Sessions included education on moral distress, palliative care and encouraged individual written reflection about difficult end-of-life situations. The sessions were led by the principal nurse investigator and palliative care clinical nurse specialist.Small and non-significant decrease observed in the nurses’ MDS-R scores post-intervention.Facilitators: To promote attendance sessions were hosted during work hours or monetary compensation was provided outside of work hours. Capping session participant size to between 3 to 10 participants stimulated discussion. Barriers: Only including nursing hindered in-depth patient care discussions and the ability to implement patient care changes.
Reilly & Jurchak (2017)Adult cardiac ICU in the United StatesQualitative focus groups conducted by the nurse ethicist and independent cofacilitator.Group discussions were hosted by nurse ethicist and unit nurse manager twice a month over 9 months. Ethically conflicting cases were chosen by nursing staff and extensively discussed.Group discussion facilitated the process of reflection and learning about moral distress. Increased nurses’ feelings of being valued. Reported decrease in moral distress and increase in growth and development on coping moral distress coping strategies.Facilitators: The skilled nurse ethicist provided structure, guidance and containment of discussion. Attendance of nursing leadership to the session implied permission for nursing staff to openly reflect and further understand daily unit practices and issues.
Rushton et al. (2021)Adult medical/surgical ICU and medical/surgical acute care units in the United StatesPerceived ethical confidence scale, moral sensitivity questionnaire, moral competence questionnaire, brief resilience scale, multidimensional emotional empathy scale, work engagement, MDT and mindful attention awareness scale.Educational curriculum including 6 sessions of training and education including role play, didactic experiential practices and group activities. Reflective debriefings facilitated following high-fidelity simulation scenarios. Educating and facilitating daily mindfulness and reflective practices.No significant changes in moral sensitivity, empathy, burnout or moral distress. Resilience and mindfulness negatively correlated with moral distress.Facilitators: Experiential learning and high-fidelity simulations were effective to enhance nurses’ skills in mitigating morally distressing scenarios. Multidisciplinary approach enhanced the educational/reflective program. Barriers: ICU nurses have a higher exposure to ethically conflicting care scenarios compared to other acute care areas and can be difficult when programs are provided to both nursing groups. Financially demanding and time-consuming program to build and implement.
Saeedi et al. (2018)Adult and neonatal ICU in IranMDS-REducational session held to teach basics of writing clinical narratives. Nurses asked to narratively write about their thoughts and emotions on their clinical practice at least once per week for 8 weeks.No significant difference in moral distress intensity and frequency between the control and test group.Facilitators: Nurses are already experienced with the skill of reflective writing from their education. Barriers: High workloads and time restrictions of the nurses. Nursing practice already includes a large amount of written work. Oral narration may be more effective. Lack of designated physical space to facilitate effective narrative writing.
Wocial et al. (2017)Pediatric ICU in the United StatesMDS-R and MDTFormal facilitated discussion about care plans for extended length of stay patients. Discussions revolved around establishing realistic goals and were held on a weekly basis. Attended by interdisciplinary team including physician, ethicist, bedside nurse, social worker, respiratory therapist and chaplain.Significant decrease in MDS-R scores from pre- to post-intervention. Range of moral distress thermometer scores narrowed with a decreased median value as the number of sessions attended increased. Largest decline seen in nurses’ moral distress post-intervention scores compared to physician scores.Facilitators: Tracking moral distress in real-time, using the moral distress thermometer, may provide opportunity to identify outliers that could benefit from an intervention. The participation of the interdisciplinary team improved communication and promoted a unified approach to patient care. Barriers: Finding an appropriate time to accommodate all team members’ schedules and accommodate outside specialties that are removed from the hospital setting.
212 excluded- did not meet inclusion criteria
113 duplicates removed
364 articles imported for screening
251 articles screened
10 articles included 
29 excluded  – 22 no moral distress measurement or intervention  – 4 wrong intervention  – 1 date of study  – 2 not English language
39 full-text articles assessed for eligibility

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram.

Adapted from “The PRISMA 2020 statement: An updated guideline for reporting systematic reviews”, by Page et al., 2021, BMJ, 372(n71), p. 5. ©2021 BMJ Publishing Group Ltd.

Author notes

Danielle Moverley, BScN, RN, Faculty of Nursing, College of Health Sciences, University of Alberta

Tanya Park, PhD, RN, Associate Professor, Faculty of Nursing, College of Health Sciences, University of Alberta

Carmel L. Montgomery, PhD, RN, Assistant Professor, Faculty of Nursing, College of Health Sciences, University of Alberta

Corresponding Author:

Danielle Moverley, BScN, RN, University of Alberta, College of Health Sciences, Faculty of Nursing, Level 3 ECHA, 11405 87 Avenue NW, Edmonton, AB, T6G1C9.

Telephone: 780-492-4547; Facsimile: 780-492-2551; Email:  moverley@ualberta.ca

Funding and Conflict of Interest Statement

The authors have no funding and no conflict of interest to declare.

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