Moral stress moral climate

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Research article

Moral stress, moral climate and moral sensitivity among psychiatric professionals

Nursing Ethics 17(2) 213–224 ª The Author(s) 2010 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733009351951 nej.sagepub.com

Kim Lu¨tzeń Karolinska Institute, Stockholm, Sweden

Tammy Blom University of Dalarna, Falun, Sweden

Beátrice Ewalds-Kvist University of Dalarna, Falun, Sweden

Sarah Winch University of Queensland, Brisbane, Australia

Abstract The aim of the present study was to investigate the association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. By means of the three scales Hospital Ethical Climate Survey, Moral Sensitivity Questionnaire and Work-Related Moral Stress, 49 participants’ experiences were assessed. The results of linear regression analysis indicated that moral stress was determined to a degree by the work place’s moral climate as well as by two aspects of the mental health staff’s moral sensitivity. The nurses’ experience of ‘moral burden’ or ‘moral support’ increased or decreased their experience of moral stress. Their work-related moral stress was determined by the job-associated moral climate and two aspects of moral sensitivity. Our findings showed an association between three concepts: moral sensitivity, moral climate and moral stress. Despite being a small study, the findings seem relevant for future research leading to theory development and conceptual clarity. We suggest that more attention be given to methodological issues and developing designs that allow for comparative research in other disciplines, as well as in-depth knowledge of moral agency. Keywords moral climate, moral sensitivity, moral stress

Background Research results1–3 have been shown to support the idea that nursing is an ‘ethically laden practice’ because moral agency, the ability to think, act and be accountable for actions taken, can be hindered by conflicting values. Moreover, these values are not always explicit.4 Stress-provoking and contradicting demands, as well as conflicting moral principles, weaken an individual’s sense of control and lack of autonomy and power.5 Eventually, stress restrains moral agency because judgment is not constantly based on careful deliberation of

Corresponding author: Kim Lu¨tzeń, Ullortstigen 1, 76021 Vato, Sweden. Email: [email protected]

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alternative choices and their consequences. Nurses can be troubled by their awareness of irresolvable competing or contradicting moral imperatives.6 There is ongoing interest and a growing need to develop practical models aimed at improving moral agency in health care,7 yet there are relevant methodological challenges. Traditionally, investigating ethical issues and decision making in health care was unacceptable and not researchable when various approaches, such as qualitative inquiry, were evaluated within the strenuous framework of the positivistic paradigm. Second, ideas about moral agency have been connected to philosophical schools of thought, particularly theology, implying that basic moral concepts are not self-explanatory. Third, when ethics in health care practice attracts the attention of disciplines such as psychology, sociology, nursing and economics, the explored ethical issues reflect the respective disciplinary focus in the concepts used. For example, from a psychological perspective, the concept of moral stress is often conceptualized as a troublesome psychological reaction. Elpern et al.8 define moral distress as ‘caused by situations in which the ethically appropriate course of action is known but cannot be taken’, and is, as such, a health risk in nursing. It seems that the term moral distress conveys a negative or undesirable situation compared with moral stress, which can also be seen as a driving force to motivate a person to become a moral agent.9 As a consequence, moral agency implies a complex phenomenon beyond a single theoretical approach. A literature review10 focusing on the concepts of moral sensitivity and hospital ethical climate, indicates that these concepts are overlapping in the ‘practical’ process of moral agency in health care. Basically, if health care workers contemplate the moral nature of their actions in an ethically difficult situation, it seems logical to assume that a positive moral climate averts a feeling of moral stress within the nurse– patient relationship. Factors contributing to emotionally difficult ethical decisions comprise conflicting values or feelings of frustration concerning insufficient or inconsistent actions relative to one’s conscience.11–14 The psychological consequence of being aware of one’s responsibility but lacking the power and resources to act on this awareness (i.e. acting in a regrettable way) confuses the logic of right and wrong.12,15 Even if nurses are capable of acting according to good judgment and premeditated choices, the cultural norms of the workplace may induce conformity and passivity.16 Their moral conviction places them at the risk of reprisal from colleagues and community.17 Despite the increasingly common attention to ethics, the possible interaction between health care personnel’s experience of moral stress, moral sensitivity and the ethical atmosphere of the workplace in encouraging or discouraging moral agency has not yet been investigated. By exploring moral agency as an interaction between several factors, our present intention is to gain a further orientation to the paths research needs to take in order to move beyond the focus on ‘the nurse’ as the sole responsible moral agent in dealing with ethical issues in nursing care.

Aim of the study Recognizing the epistemological and subsequently the methodological problem of operationalizing ‘nonmeasurable’ dimensions such as moral sensitivity, the aim of the present study was to investigate whether there is an association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. The study was conducted within the psychiatric field because of this sector’s documented ethical conflict instigating insecurity in both staff and patients.18 For example, Severinsson and Hummelvoll19 portray the job situation for nurses working and interacting with patients in acute psychiatry as an employment environment where nurses constantly tolerate the pressure of ‘treatment effectiveness’ causing them ‘work-related stress’, and in which organizational demands conflict with nurses’ perception of the idea of good nursing care.

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Conceptual framework The conceptual framework for the present study connects three concepts: moral stress, moral climate and moral sensitivity. These concepts are basic to the idea that moral agency is a nursing responsibility but also an interactive process.

Moral stress ‘Work-related’ stress and overload for nurses have been linked to professional ethical demands and poor patient outcomes.20–23 Although there appears to be a general agreement that these situations arouse some type of stress reaction, different terms are used (i.e. moral distress, moral stress). Jameton employs the term moral distress and explains its cause as in a situation ‘when one knows the right thing to do, but institutional constraints makes it nearly impossible to pursue the right course of action’ (p.6).24 Wilkinson25 adds that moral distress is a psychological disequilibrium with negative feelings in such a situation. Frustration, anger and anxiety, according to Jameton,24 are indications of initial distress in conflict situations and reactive distress is experienced by people when they do not act upon their initial distress.21 Corley et al.26 developed the Moral Distress Scale based on Jameton’s theoretical definition. The definition of moral perplexity as ‘distress’ implies that the focus in research is placed on the psychological reaction rather than on the ethical issues in a specific situation.23 This latter focus is exemplified by Zuzelo,27 who defines ‘moral’ stress as efforts or attempts to make clinical decisions involving conflicting ethical principles and where patients’ autonomy is at risk. Moral dilemmas cause stress inasmuch as the decision making process can be questioned. We acknowledge the difficulty in bringing clarity to the difference in meaning of the concepts of moral stress and moral distress. However, in our study, we use the term moral stress in close connection to Zuzelo’s definition in a tentative manner.

Moral climate The ability for nurses to process and resolve ethical dilemmas has also been linked to their experience of ethical dilemmas related to the atmosphere of the work setting.28 Joseph and Deshpade21 found that health care facilities that attract and retain nursing staff in a competitive environment that provides high-quality nursing care, also create an atmosphere that supports nurses to resolve and process their ethical concerns. Nurses’ ability to process and resolve ethical dilemmas has been found to be linked to their experience of ethical dilemmas throughout their affiliation to the health care facility, that is, experience of the moral climate of the work setting as well as throughout their relationship with patients.21 The concept of moral climate in health care systems can be used metaphorically to describe the workplace atmosphere that is conducive to dealing with ethical problems and fosters ethical practice. Spencer et al.,29 based on the work of Victor and Cullen,30 describe ‘organizational’ ethical climate as constituting the ‘shared perceptions of the general and pervasive characteristics of an organization affecting a broad range of decisions’ (p.6). A positive ethical climate is reflected by an organization’s vision simultaneously with its practiced goal. Most notably, a positive moral climate embodies a set of values that replicates societal norms that are consistent with ethical practice (p.6).29 Rodney et al. define moral climate in the context of health care as the ‘implicit and explicit values that drive health care delivery and shape the workplaces in which care is delivered’ (p.24).31 According to Olson,28 moral climate refers to an ‘individual perception of the organization that influences attitudes and behavior and serves as a reference for employee behavior’. However, factors such as cutbacks in health delivery, complexity of patient care, and advances in medical technology contribute to situations in which nurses (and other health care staff) feel unable to work according to the implicit or explicit values they

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are committed to follow. In the practice of triage32 (i.e. sorting and selecting for the purpose of medical treatment, based on the principle of utilitarianism) ethical issues in nursing arise when prioritization of patient needs means that some patients do not receive the care they should. However, in daily practice, nurses are also obliged to prioritize their care and to be able to reflect on ethical issues in a work climate that is morally supportive.

Moral sensitivity The position that ‘moral distinctions originate in the sentiment and not in reason alone’ was taken by British moral philosophers in the seventeenth century, a group referred to as ‘sentimentalists’.33 The ‘moral sense’ was thought to close the gap between moral knowledge and moral behavior by providing a motive for action.34,35 Shaftesbury, who was the first British philosopher to develop the idea of the ‘moral sense’, argued that in order for ‘man’ to be virtuous ‘he’ must be capable to reflect on his ‘actions’ and ‘affections’. Hutcheson aligned on the whole with Shaftesbury’s theory of the function of [moral] reflection and claimed that moral ‘ideas’ are derived from ‘the’ moral sense. Through this moral sense ‘pleasures and pains’ are generated, in other words, that which is either good or evil.34 Translated into modern vocabulary, we suggest that ‘pleasures’ can refer to a good conscience and ‘pains’ to a bad conscience, perhaps expressed as bodily or emotional reactions that may bring us closer to the concept of moral stress. Modern phenomenological ethicists, especially Tymieniecka, extended the idea of the moral sense by suggesting that the ‘benevolent sentiment’ functions in the intersubjective interpretation of conflicting situations: ‘it is the benevolent sentiment at work, introducing ultimately the moral axis of right/wrong that establishes the inter-subjective life-sharing’ (p.34).36 Tymieniecka refers to the ‘evaluative process’ (p.35) by which the benevolent sentiment presents itself. In short, in this decision-making process judgments do not concern only a moral act based on approbation (praise, approval) or disapprobation, without benevolence towards the other being present. This means that moral agency is manifested by benevolence and moral responsibility for the well-being of all living beings.36 Lu¨tzeń and Nordin37 elucidated the concept of moral sensitivity in a grounded theory study of nurses’ moral decision making in mental health care. Moral sensitivity was defined as an understanding of patients’ vulnerable situation as well as an awareness of the moral implications of decisions that are made on their behalf. This interpretation of moral sensitivity is concordant with the idea that moral agency is both a cognitive and an inter-relational process. In later work6 the concept moral sensitivity was broadened and involved more dimensions than cognitive capacity, especially feelings, sentiments, moral knowledge and skills. This concurs with Manning’s38 concept of ‘moral citizenship’ that includes the components awareness, thinking, feeling and action.

Method Participants A convenience sample of a psychiatric sector comprising an estimated population of 100 nurses, enrolled nurses and psychiatric enrolled nurses employed in four acute psychiatric hospital wards belonging to the same psychiatric clinic in central Sweden were asked to participate in the present study. The only selection criterion was that the participants were employed on one of these wards. Out of 100 questionnaires delivered to managers of these wards, 49 were completed and returned. The participants’ demographic data are provided in Table 1.

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Table 1. Participants’ demographic data and differences between groups Variable/s Age (years) Total Women Men Marital status Married/cohabiting Single Children Yes Sex/work-related stress Female Male Sex/bad conscience Female Male Felt inept when caring for patients Nurses with children Nurses without children Profession Nursing assistant Mental health nurse Nurse Professional experience (years)/support from the manager 1–5 6–10 >10 Felt did not have time to do enough for patients Specialist nurses Non-specialist nurses

No.

Mean (SE)

t (df)

P-value

39 26 13

33.15 (4.78) 28.73 (5.40) 42.00 (6.57)

1.561 (27.7)

0.130 (2-tailed)

31 13 24

1.55 (0.08)

29 17

3.03 (0.15) 2.53 (0.21)

2.030 (44)

0.048 (2-tailed)

29 17

2.93 (0.18) 2.18 (0.20)

2.718 (44)

0.009 (2-tailed)

24 20

2.79 (0.21) 2.30 (017)

1.856 (42)

0.036 (1-tailed)

2.940 (36.3)

0.006 (2-tailed)

2.262 (42)

0.029 (2-tailed)

9 20 17 13 3 30

26.77 (0.61)

15 29

3.20 (0.20) 2.62 (0.15)

24.04 (0.70)

Ethical considerations The Director of the Department of Psychiatry and four head nurses approved the study and the wards in which it was carried out. The participants were given written information: that their participation was voluntary and that their identity would not be revealed. Any written comments that risked identity disclosure were not to be published. In addition, the participants were informed of their right to withdraw from participation in the study at any time without adverse consequences. Informed consent was considered to be guaranteed when the questionnaires were returned and answered. This study was approved by the local Regional Research Ethics Committee.

Data-collection: questionnaires Hospital Ethical Climate Survey. The nurses’ experience of the moral climate was investigated using the Hospital Ethical Climate Survey. This is a 26-item questionnaire with five response alternatives, developed by Olson,28 and translated into Swedish with permission of the original author. Psychometric properties showed good validity and reliability for the Swedish version (Cronbach’s alpha ¼ 0.85). From the Hospital Ethical Climate Survey a subscale named ‘Moral support’ comprising six items (Cronbach’s alpha ¼ 0.89)

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was constructed as follows: My colleagues listen to my doubts about patient care; When I cannot decide what is right or wrong in a nursing situation, I get help from my manager; My manager supports me in my decisions regarding nursing; My manager listens to me when I talk about a nursing problem; My manager is someone I can trust; and When my colleagues cannot decide what is right or wrong in a specific care situation, I have observed that my manager helps them. Moral Sensitivity Questionnaire. The original Moral Sensitivity Questionnaire (MSQ) containing 30 items was developed in the context of psychiatric care, but later modified and used in other clinical settings. In a revised version, developed by Lu¨tzeń et al. in a previous study,6 the number of items in the questionnaire was reduced to nine, with six response alternatives. A factor analysis with varimax rotation generated three factors: sense of moral burden, moral strength and moral responsibility. The Eigenvalues for these three factors were: moral burden 2.849, moral strength 2.184 and moral responsibility 1.368.6 Work-Related Moral Stress questionnaire. The Work-Related Moral Stress (WRMS) questionnaire, developed for the purpose of this study, consists of nine items (with five response alternatives) related to general symptoms of stress: Have you felt during the last month that:

You are physically tired You cannot offer the care you wish to do You find it difficult to relax during your leisure time You suffer from sleep deprivation You do not have time to do more for your patients You suffer from a bad conscience because you cannot offer the care you wish to do You feel inept because you are unable to carry out care as you wish You think about quitting health care work You are mentally tired

The WRMS questionnaire was tested in a pilot study with 46 nurses. A factor analysis using varimax rotation confirmed the relationship of the items to the factors and reliability (Cronbach’s alpha ¼ 0.91). Statistical analysis Using SPSS 15.0, Cronbach’s alpha reliability analysis, linear regression analysis, analysis of variance (ANOVA) with Tukey’s Honestly Significant Difference (HSD) post-hoc test and Pearson’s correlation coefficient. A non-significant Kolmogorov–Smirnoff statistic (P > 0.05) indicated normality. The scales comprised five to six response categories that changed in a quantitative way and thus reflected interval-scale data, and permitted the computation of standard multivariate regression analysis for the present small sample.39 The moral sensitivity items were computed separately in the regression analysis because they lacked internal consistency; they nevertheless contributed to the results.

Results Demographics Sex and specialization. The participants’ characteristics and differences are shown above in Table 1. No age difference was found between male and female nurses but sex differences were revealed for work-related stress. Female nurses felt more so than men that during the previous month they did not have time to do enough

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5

Score

4

3

2

1 ≤43

44−54

≥55

Figure 1. Nurses’ sleep deprivation during previous month according to age group (43 years: M ¼ 2.00 (SE ¼ 28) versus 44–54 years: M ¼ 3.07 (SE ¼ 0.32) t(27) ¼ 2.523; P ¼ .018; Tukey’s Honest Significent Difference post-hoc test P ¼ 0.027)

for their patients. Female nurses also suffered more from a bad conscience compared with male nurses during the previous month because of not being able to carry out the nursing actions they desired. In addition, compared with those without children, nurses with children felt more inept during the previous month, because of not being able to carry out the care they wished. Non-specialist nurses, when compared with specialist colleagues, felt that during the previous month they did not have time to do enough for their patients. Age and sleep deprivation/dealing with emotions/professional experience. The participants were divided into three age groups: 43, 44–54 and 55 years. Using ANOVA, a difference in experienced sleep deprivation was found between age groups (F[2.36] ¼ 4.067, P ¼ 0.026). Tukey’s HSD indicated that nurses aged 44–54 years suffered more from sleep deprivation than those aged 43 (M ¼ 3.07 [SE ¼ 0.32] versus M ¼ 2.00 [SE ¼ 0.28]; MD ¼ 1.067, P ¼ 0.027) (Figure 1). Out of 15 nurses aged 44–54 years, 11 suffered sometimes/almost daily or daily from sleep deprivation. Furthermore, nurses aged 44–54 found it more difficult to deal with their emotions when a patient was suffering, than those aged 43 years or younger (M ¼ 2.73 [SE ¼ 0.15] versus M ¼ 2.07 [SE ¼ 0.22]; t(27) ¼ 2.486, P ¼ 0.019, 2-tailed). A statistically significant difference between age group and years of professional experience was also found (M (4) ¼ 24.30, P ¼ 0.000).

Moral sensitivity and professional experience Nurses with 1–5 years of professional experience tended to be less morally sensitive compared with those with 6–10 years’ practice (M ¼ 31.38 [SE ¼ 1.62] versus M ¼ 37.33 [SE ¼ 0.67]; t(14) ¼ 1.713,

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P ¼ 0.0545, 1-tailed). In addition, nurses with 1–5 years of professional experience felt more optimistic about the moral climate of the workplace compared with those who had 6–10 years’ experience (M ¼ 103.9 [SE ¼ 2.35] versus M ¼ 91.0 [SE ¼ 8.02]; t(14) ¼ 2.138, P ¼ 0.026, 1-tailed). Furthermore, nurses with 1–5 years of professional experience compared with those with more than 10 years, reported more support from their managers and colleagues (M ¼ 18.23 [SE ¼ 0.47] versus M ¼ 16.72 [SE ¼ 0.46], t(40) ¼ 1.998, P ¼ 0.053, 2-tailed). Nurses with 6–10 years of professional experience compared with those with more than 10 years had felt more satisfied with their nursing care during the previous month (M ¼ 3.0 [SE ¼ 0.00] versus M ¼ 2.7 [SE ¼ 0.13], t(29) ¼ 2.340, P ¼ 0.026, 2-tailed), and also agreed more than nurses with 1–5 years of experience to the statements measuring moral sensitivity: ‘I have a very good ability in knowing how to talk to patients about difficult matters’ (M ¼ 5.67 [SE ¼ 0.33] versus M ¼ 4.54 [SE ¼ 0.27]; t(14) ¼ 1.911, P ¼ 0.039, 1-tailed) and, ‘It is easy to know what is good or bad for the patient when I can work according to the established procedures and rules’ (M ¼ 5.67 [SE ¼ 0.33] versus M ¼ 3.69 [SE ¼ 0.43], t(14) ¼ 2.126, P ¼ 0.026, 1-tailed). A total of 10 of 14 nurses with more than 10 years’ professional experience reported that during the previous month they were thinking almost daily or daily about quitting working in health care. By means of univariate ANOVA it was revealed that the interaction between sex and professional experience impacted ‘moral burden’ (F[2.44] ¼ 3.273, P ¼ 0.048).

Moral stress by moral climate The aim of this study was to determine whether work-related moral stress could be explained by the moral climate at the place of work as well as by moral sensitivity. Professional experience was shown to correlate negatively with the work-related moral climate (r(38) ¼ –0.351, P ¼ 0.026). A standard multiple linear regression analysis was performed to determine if moral stress was affected by items of moral sensitivity in addition to effects of the moral climate. It was shown that the moral climate, together with two items of moral sensitivity, predicted 33.7% of the moral stress (Table 2). The moral climate predicted 10.2% of the moral sensitivity expressed in moral stress. Further moral sensitivity in terms of ‘In meeting with patients, I am always aware of the balance between the ability to do good, and the risk of causing harm’ predicted 10.2% of the moral stress. Furthermore, 11.5% of the moral stress was predicted negatively by the claim ‘I have a very good ability in knowing how to talk to patients about difficult matters’ (Table 3). Pearson correlation coefficients were computed between moral stress and moral climate in addition to the nurses’ experience of moral understanding and moral support, factors that increase or decrease the experience of moral stress. A negative correlation between moral stress and moral climate was revealed (r(43) ¼ 0.398, P ¼ 0.004). In other words, experience of a negative moral climate increased moral stress. Additionally, moral stress correlated positively with experienced moral understanding (r(48) ¼ 0.414, P ¼ 0.002) (i.e. the more morally aware the more morally stressed), but negatively with the experience of moral support (r(46) ¼ 0.379, P ¼ 0.005). The moral climate correlated negatively with experienced moral stress (r(44) ¼ 0.309, P ¼ 0.021) and the latter correlated negatively with the experience of moral support (r(44) ¼ 0.303, P ¼ 0.019).

Discussion The aim of this study was to explore whether professional moral stress can be predicted by the moral climate and/or by moral sensitivity in a psychiatric setting comprising four acute psychiatric hospital wards. The statistical analysis revealed that participants aged 44–54 years with typically more than 10 years’ professional experience suffered from sleep deprivation more than other age groups. Furthermore, the participants in this age group reported support from their managers and colleagues to a lesser extent and often thought about quitting their job. In addition, members of this group found it difficult to deal with emotions when a patient

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Table 2. Model summary for the standard linear regression analysis R

R2 (% explained)

Adjusted R2

Standard error of the estimate

0.580

0.337 (33.7)

0.267

5.024

Table 3. Linear multiple regression analysis with the dependent variable moral stress

MSQ item Constant Moral climate In meeting with patients, I am always aware of the balance between the ability to do good and the risk of harm I have a very good ability in knowing how to talk to patients about difficult matters I find it very hard to cope with my emotions when meeting with patients who are suffering

Unstandardized beta coefficient (SE)

Standardized beta coefficient (% explained)

40.412 (10.090) –0.174 (0.079) 1.702 (0.751)

0.319 (10.2) 0.319 (10.2)

4.005 –2.203 2.265

0.00 0.034 0.029

–2.191 (0.909)

–0.339 (11.5)

–2.409

0.021

1.302

0.201

1.341 (1.030)

0.189 (0.036)

t-value P-value

MSQ, Moral Sensitivity Questionnaire.

was suffering and they felt less satisfied with their nursing care during the previous month compared with contentment experienced by the other age groups. These observations indicated that the group in question was under some kind of stress. For example, Lawoko et al.40 demonstrated that psychiatric nurses were often targets for violence at age