Improving Moral Distress In Healthcare Professionals: A Reflective Essay Protocol.

Use full sentences to answer the questions within the criteria, and provide rationales for your decisions (citing sources).

Introduction (no heading). Give the reader a sense of what to expect in this paper (identify the article being appraised [cited appropriately] and state what parts of the appraisal will be included in this paper).  The introduction should be brief and not include information that should be discussed in subsequent sections of the paper. One short paragraph is required.  

Population, Sample, & Setting. What was the population for the study? Identify the specific sampling method used for the study.  Discuss the adequacy of the sampling method for producing a sample representative of the population.  Discuss potential biases with the sampling method used.  Identify the inclusion and exclusion criteria used in the study.  Discuss appropriateness of the sampling criteria for the study?  Discuss how the planned sample size was determined (including power analysis & consideration of potential attrition if included).  Discuss actual sample size attained for the study including acceptance rate, refusal rate (including rationale for refusal to participate if presented), and attrition rate.  Describe study setting and its appropriateness for the study.

Legal & Ethical Issues.  Briefly discuss institutional review board approval for the study.  Explain how ethical principles of research (beneficence, justice, & respect for human dignity) were followed to protect subjects’ rights (freedom from harm, privacy, autonomy, & disclosure).  If the study included subjects from a vulnerable population, were additional safeguards used to protect them?

Measurement. Identify and describe the instrument(s) used to measure the major study variables (research or dependent variable[s]).  Identify the level of measurement (LOM) achieved by each instrument.  Discuss the psychometric properties (reliability & validity of questionnaires/scales or precision & accuracy of physiologic measures) of instrument(s) used in this study (authors’ description of instruments’ past reliability/validity & reliability/validity from current research). (15 pts)

Data Collection. Describe data collection procedures used in the study.  Discuss clarity of description of data collection process.  If more than one data collector was used for the study, describe the training of the data collectors and how/whether interrater reliability was adequately assessed/ensured?

Data Analysis.  List the statistical procedures performed to describe the sample.   List the statistical procedures performed to answer the research question(s).  Discuss appropriateness of statistical procedures for the LOMs of data collected.  Discuss appropriateness of statistical procedures used to address the study purpose/question/hypotheses.  Discuss clarity of description of data analysis procedures.  Did the researcher(s) address management of problems with missing data?  What level of significance (alpha) was set for this study?  Discuss the clarity of presentation of study results (if tables or figures were used, briefly describe them & discuss if/how they made the presentation more understandable).

Researcher Interpretation of Findings. Describe the key findings of the study in relation to purpose/question/hypothesis.  Discuss the clarity of the authors’ explanation of key findings, including statistically significant & non-significant findings.  Discuss whether the key findings were clinically significant/clinically important.  Describe which findings were consistent with those expected.  Describe which findings were unexpected.  Were findings linked to the study framework?   Describe the study’s limitations identified by the authors.  Did the study have limitations not identified by the authors?  Did the authors identify potential threats to design validity?  Did the authors generalize the findings to other populations?  If so, to what populations were generalizations made?  Discuss appropriateness of any generalizations.  What implications for practice were identified by the authors?  What suggestions for future studies were identified by the authors?

Overall Evaluation of the Study.  Discuss whether/how the study built upon previous research (problems, purposes, designs, samples, &/or measurement), providing examples for support.  Discuss at least one strength of the study.  Discuss at least one weakness of the study and whether/how that weakness could have been corrected.  Discuss credibility of study findings and how much confidence can be placed in them.  Based on the previous research presented in the ROL and the findings of the study presented in this article, discuss whether the findings are ready for use in practice.  Were relevant studies suggested for future research?

Healthcare workers are often seen to experience moral distress if they face situations where they are forced to conduct certain practices which according to their code of conduct are deemed ethically wrong. These ethical dilemmas often occur in situations like end-of-life decision making, limited resource utilisation, prioritising the treatments of different patients, as well as non-beneficial treatment (Geppert & Shelton, 2012). The aim of this research was to test and develop a protocol to help in improving the condition of moral distress in healthcare professionals like nurses especially in clinical settings like ICU and palliative care with the help of reflective debriefings (Browning & Cruz, 2018). The article collects reflective data from the nurses in the ICU as well as nurses involved in the social work to help understand the different moral dilemmas they face during their service with and without the inclusion of clinical interventions to help cope against these (Browning & Cruz, 2018). Thus, this research helped understand the ways with which they can successfully and effectively eliminate the addressable doubts and concerns of the healthcare professionals to avoid associated mental risks like burnout, reduced professional performance and productivity, as well as detachment. The appraisal identified the sample population and setting, logical and ethical issues, measurement, data collection method, and data analysis as well as the interpretation of the article.

The nurses and healthcare professionals working in the ICU as well as the ones providing palliative social services were the sample population of the study.  The inclusion criteria of the survey for the sample population  was the ICU nursing population consisting of nurses of different demographics like age, race, and gender as well as nurses with different working experiences, from  MDS  to registered nurses. A convenience sampling method of the sample population was employed for the survey. The participants didn’t even require filling out the entire questionnaire to take part in the survey, which can cause some inconsistency in the data collection process, leading to inaccurate analysis of results of the survey.  The only identifiable exclusion criteria of the sampling method of the survey would be that the sample population would require being healthcare professionals working in the ICU. The idea of the reflective debriefing was mentioned in a staff meeting, where nurses of different working experiences as well as demographics like age, race, and gender were given an equal chance to participate. The total number of the participating nurse was 43 with a response rate of 61% (Browning & Cruz, 2018). Out of the 27 nurses, 1 nurse completed the five stages of the debriefing sessions; however, three showed up for four sessions, five went to three sessions, eight attended to two sessions, and two went to one debriefing session. A total of 11 nurses did not attend a single session (Browning & Cruz, 2018).

Complying by ethical procedure to protect research participants from any harm and avoiding conflict during research process is critical for a high quality research. The researchers followed ethical principles of research by taking approval from health system’s institutional review board (IRB). In addition, ethical principle of human dignity, privacy and autonomy was maintained by providing cover letter with written information about the project to all participants and taking participants after completing informed consent process. Confidentiality was maintained by taking unique identifiers instead of name of each participant. As study included no vulnerable population group, no addition measure to safeguard and protect participant’s interest was required.

The primary research variable of interest in the article included moral distress which was measured by MDS-R, a 21 item scale to measure moral distress in nurses working in ICU and non-ICU setting. Browning and Cruz (2018) gave detailed description of past reliability, validity and reliability of the scale from current research. The author explained about the past version of the tool and the challenges associated with it. In addition, the researcher defined the advantage of the current version of the tool which included the advantage of completing assessment based on variety of clinical situation. Description was given regarding the scoring range of the tool and the way scores are calculated. The rating was given on 0-4 Likert scale. Low score was given for items rarely experienced and high score was given for items experienced frequently and as most distressing. Evidence was given regarding the construct validity and reliability of the tool. However, one major limitation in reporting about psychometric properties is that the author did not gave idea about numerical data related to construct validity of the tool. However, Lamiani et al. (2017) focused on investigating about the internal consistency of the tool and filling the gap related to lack of validation of the revised scale. The study showed that the MDS-R has a good internal consistency of α=.81. Hence, because of good psychometric properties, the tool used in the study is accurate as it addresses different components of moral distress in different clinical situation.  However, the length of the scale used is a limitation as it affected completing the test for nurses because of longer time required.

As Browning and Cruz (2018) conducted the research using a pre/post-test experimental design, data was collected using both before and after the intervention. MDS-R was administered to ICU nurses to collect data related to baseline moral distress and the same tool was used again after 6-month period of the intervention. However, one major limitation in research reporting is that detailed description of data collectors is missing. The paper does not provide clear insight related to the staffs who were involved in data collection. No qualification details or experience details was given too to understand the validity of the data collection method. It is not clear whether one staffs or more than one staff was involved in data collection. This again reflects lack of consideration of interrater reliability during data collection too. Interrater reliability is an important process that helps to minimize biases during data collection by ensuring agreement of the same data by different raters (Burns, 2014). Hence, as no consensus was established between researchers, data collection method is not reliable.   

Measurement

The statistical process that was performed to report about research findings and answer the research question included use of descriptive statistics, Two-tailed partial correlations, independent t-test, Mann–Whitney U test, and regression analyses. All these were analyzed using the Statistical Package for the Social Sciences (SPSS). Browning and Cruz (2018) described about the reason for using each statistics procedure. For example, Two-tailed partial correlations were conducted to identify correlation between nurse characteristics and the moral distress distress. Use of this statistical tool is appropriate as when the purpose is to measure the strength of two variables with a linear relationship. It also helps to control for the effect of one variable over the other (Solutions, 2016). Hence, as moral distress is highly linked to nurse characteristics, controlling for this effect using partial correlation is an appropriate statistical method used. In addition, other statistical tools were used to analyse relationship and differences between study outcomes. Use of independent t-test is appropriate as it determines statistical difference between two groups. Furthermore, regression analysis facilitates analysis of a dependent variable based independent variables (Kraemer & Blasey, 2015).

The overall statistical analysis was done using SPSS. It is popular software used to perform all statistical operations in research. The main advantage of this software is that it can lead to correctly run all statistics test and interpret statistical output. The level of significance for all the statistical test was set at < 0.05. This can help to determine the values based on which null hypothesis can be rejected when it is true (Kraemer & Blasey, 2015). However, despite this description, no details about missing data were given. Despite this limitation, the significance of data analysis method is that study results were clearly presented using several tables. Representation of outcomes for moral distress frequency and moral distress density clearly demonstrated different situations during which moral distress was experienced.

The survey reported that the briefing sessions with fellow colleagues, has helped in the recognition of nursing dilemmas and concerns as well as facilitated the formation of effective and functioning teams. The limitation identified by the authors was the lack of qualitative research conducted for the project. Apart from the mentioned limitation in the article, the project had several other limitations like the small sample size which incorporates the nursing population of one critical unit of one healthcare facility. Another limitation that can be observed is the lack of data distribution according to the different demographics of the nursing population. The third limitation can be considered as the participants didn’t even require filling out the entire questionnaire to take part in the survey, which can cause some inconsistency in the data collection process, leading to inaccurate analysis of results of the survey.  

Data Collection

Given the several different demographics present in the participating sample population, the experiences are bound to be significantly different considering their different beliefs and cultural ethics. The authors had to generalise the evaluation of the intensity and incidence of moral distress in critical situations. This generalisation was done to provide an overview on the effectivity of reflective debriefing for providing some mental and emotional aid in times of mental distress (Lavoie, Pepin & Boyer, 2013). The project focussed on helping the healthcare professionals manage and overcome the overwhelming emotions through the means of effective communication. The study emphasized on the importance of effective communication and teamwork.  

The study highlighted that there was a significant gap in palliative care and social work literature regarding moral distress. They also mentioned that there was limited availability of evidence based literature regarding testing interventions based on moral distress. The study mentioned that further incorporation of different improvements can be done to the Reflective Debriefing sessions to help acquire accurate data and understand the situation or risk factors better in order to help formulate effective interventions for the cause.

The rationale of the project was to help understand the moral distress of the healthcare professionals in clinical settings like the ICU during situations like end-of-life decision making, limited resource utilisation, prioritising the treatments of different patients to aid in devising effective distressing interventions to avoid reduction in professional productivity as well as burnout (Shakerinia, 2012). The strength of the project would be its aim to understand and analyse the different effects of the interventions used to reduce the moral distress of the nurses working in stressful clinical settings like the ICU. The article provides an effective literature review on the existing research of the key topics of the project. One of the most important strengths is the diverse sample population belonging to different designations, which can provide the different intensities of moral distress at each level of nursing (Rodger, Blackshaw & Young, 2019). The project employs a direct method of data collection, where the information is collected directly from the nurses to provide their personal insight on the efficacy of the reflective debriefing sessions on reducing the incidence of moral distress. This, hence, increases the accuracy of the analysis as well as the results obtained from the survey.  The weaknesses of this research would be the small sample size, lack of mention of the different demographics of the sample population, and the inclusion of incomplete survey questionnaire forms in the survey.

Considering the small sample population, the findings of the study cannot be considered very accurate. However, if this process of Reflective Debriefing incorporates a bigger sample population, and differentiates the data collected as per the different demographics, then the results obtained might be more accurate and help in facilitating the incorporation of effective interventions.

References:

Browning, E. D., & Cruz, J. S. (2018). Reflective debriefing: a social work intervention addressing moral distress among ICU nurses. Journal of social work in end-of-life & palliative care, 14(1), 44-72.

Burns, M. K. (2014). How to establish interrater reliability. Nursing2019, 44(10), 56-58.

Geppert, C. M., & Shelton, W. N. (2012). A comparison of general medical and clinical ethics consultations: what can we learn from each other?. In Mayo Clinic Proceedings (Vol. 87, No. 4, pp. 381-389). Elsevier.

Kraemer, H. C., & Blasey, C. (2015). How many subjects?: Statistical power analysis in research. Sage Publications.

Lamiani, G., Setti, I., Barlascini, L., Vegni, E., & Argentero, P. (2017). Measuring moral distress among critical care clinicians: validation and psychometric properties of the Italian Moral Distress Scale-Revised. Critical care medicine, 45(3), 430-437.

Lavoie, P., Pepin, I., & Boyer, L. (2013). Re?ective debrie?ng to promote novice nurses’ clinical judgment after high-?delity clinical. Dynamics, 24(4), 36-41.

Rodger, D., Blackshaw, B., & Young, A. (2019). Moral distress in healthcare assistants: A discussion with recommendations. Nursing ethics, 26(7-8), 2306-2313.

Shakerinia, I. (2012). Moral distress, burnout and mental health in nurses of YAZD.

Solutions, S. (2016). Correlation. Pearson, Kendall, Spearman). Accessed October, 18, 2016.