https://journal.chestnet.org/article/S0012-3692(12)60137-8/pdf

Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

http://icnapedia.org/guidelines/open/Chest-2008-Monagle-887S-968S.pdf

Antithrombotic Therapy in Neonates and Children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

First defined by Jameton in 1984 as a phenomenon that occurs when nurses cannot carry out what they believe to be ethically appropriate actions because of institutional constraints, moral distress has recently gained attention as an important problem experienced by multiple healthcare disciplines.1 Although it is not a new topic, recent attention to moral distress (specifically, an article in the New York Times by surgeon Pauline W. Chen, “When doctors and nurses can’t do the right thing,”2 and a fourfold increase in articles on the topic in MEDLINE in the past two years) has highlighted its presence and effect on healthcare providers and on the delivery of healthcare. While the majority of published research has been in nursing journals, current work has expanded to other disciplines, including medicine, psychology, pharmacy, and respiratory therapy.3 It is increasingly clear that moral distress is not solely a nursing issue, but one that potentially influences all healthcare professionals.

Jameton described moral distress as having two parts: initial distress and reactive distress.4 Initial distress occurs in the moment, as a situation unfolds (from this point forward, we will use the phrase moral distress to refer to this acute phase). After the situation that elicited moral distress ends, reactive distress (now referred to as moral residue) remains. Hence, moral distress and moral residue are closely related but separate concepts. Thus far, distinctions between the two have largely not been addressed empirically or conceptually; however, the two phenomena have differing characteristics and their interrelationship poses important implications for members of healthcare teams.

The aim of this article is to propose a preliminary model that we call the crescendo effect, which describes the interrelationship between moral distress and moral residue. Our intent is to spark debate, encourage further study, and provide additional insight for ethics consultants as they analyze clinical situations.

While the crescendo effect model arose from an empirical study of experienced nurses and physicians in a neonatal intensive care unit (NICU),5 mounting evidence from other disciplines and settings indicates that the phenomenon is shared across many specialties. We will provide examples from these sources and settings in this article.

Moral Distress, Moral Residue, and the Crescendo Effect

https://journal.chestnet.org/article/S0012-3692(15)60797-8/pdf

Antithrombotic Therapy in Children

Background: Although moral distress is increasingly recognized as an important problem that threatens the integrity of health care providers and health care systems, few reliable and valid measures of moral distress are currently in use in research or clinical practice. This article describes the development and testing of a revised measure of moral distress, the Moral Distress Scale–Revised (MDS-R), designed for use in multiple health care settings and with multiple disciplines. Methods: After instrument development and content validity testing, a survey methodology was used to assess reliability and construct validity of the MDS-R. Registered nurses (n = 169) and physicians (n = 37) in eight intensive care units (ICUs) at an academic medical center in the southeastern United States participated; the survey was administered during a 2-week period in January 2011. Results: Adequate reliability and evidence of construct validity were demonstrated. Moral distress was significantly higher for nurses than phy...

https://www.tandfonline.com/doi/pdf/10.1080/21507716.2011.652337

Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals

Moral Distress in Healthcare Practice: The Situation of Nurses

The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice.

To stay or to go, to speak or stay silent, to act or not to act: moral distress as experienced by psychologists.

In this Canadian study, a participatory action research approach was used to examine the relationships between families of residents of traditional continuing care facilities and the health care team. The objectives were to (a) explore the formation and maintenance of family—staff relationships, with attention paid to the relational elements of engagement and mutual respect; (b) explore family and staff perspectives of environmental supports and constraints; and (c) identify practical ways to support and enhance these relationships. Results indicate that the resource-constrained context of continuing care has directly impacted family and staff relationships. The nature of these relationships are discussed using the themes of “Everybody Knows Your Name,” “Loss and Laundry,” “It's the Little Things That Count,” and “The Chasm of Us Versus Them.” Families' and staff's ideas of behaviors that support or undermine relationships are identified, as are concrete suggestions for improving family— staff relationshi...

Gillian Lemermeyer

Papers

Moral Distress in Healthcare Practice: The Situation of Nurses

To stay or to go, to speak or stay silent, to act or not to act: moral distress as experienced by psychologists.

Supporting Relationships Between Family and Staff in Continuing Care Settings

Reduction of leg wound infections following coronary artery bypass surgery.

Modified Blalock-Taussig shunts: to heparinize or not to heparinize?