STRATEGIES FOR COPING WITH MORAL DISTRESS ADOPTED BY NURSES IN TERTIARY CARE: A SCOPING REVIEW

ESTRATEGIAS PARA AFRONTAR EL SUFRIMIENTO MORAL ADOPTADAS POR ENFERMEROS EN EL NIVEL TERCIARIO DE ATENCIÓN: SCOPING REVIEW

ABSTRACT

Objective:

to map the scientific evidence on strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care.

Method:

this is a Scoping Review based on the PRISMA-ScR recommendations. The searches were performed in September 2020 in the MEDLINE^®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane and Biblioteca Virtual en Saúde databases. The eligibility criterion was to include studies that discussed strategies for coping with moral distress adopted by nurses in tertiary care, finding 2,041 studies, which were organized and screened in the Endnote software. The data were organized in Excel spreadsheets and analysis of the results was performed using the ATLAS.ti software.

Results:

the final selected sample consisted of 23 studies, which were grouped in two axes: strategies and recommendations. Four articles were included in the “strategies” axis, which reported actions taken to face moral distress, detailing the intervention and their results. The others, included in the “recommendations” axis, are articles whose focus was the experience of moral distress, suggesting important aspects to face it.

Conclusion:

recognition of moral distress by nurses and the opportunity for collective discussion and exchange of experiences are ways of collectively facing the situations. In addition, the institution's active participation in carrying out interventions was recommended. However, gaps were noticed in the production of studies that actually go deeper into intervention actions to cope with moral distress.

DESCRIPTORS:
Nursing; Psychological adaptation; Psychological stress; Moral; Ethics in nursing; Hospital

RESUMEN

Objetivo:

mapear las evidencias científicas sobre diversas estrategias para afrontar el sufrimiento moral adoptadas por enfermeros en el contexto de los servicios de salud en el nivel terciario de atención.

Método:

Scoping Review basada en las recomendaciones PRISMA-ScR. Las búsquedas se realizaron en septiembre de 2020 en las siguientes bases de datos: MEDLINE^®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane y Biblioteca Virtual de Saúde. El criterio de elegibilidad fue incluir estudios que debatieran estrategias para afrontar el sufrimiento moral adoptadas por los enfermeros en el nivel terciario de atención, con lo que se encontraron 2.041 estudios, que se organizaron y seleccionaron en el software Endnote. Los datos se organizaron en planillas de Excel y se realizó un análisis de los resultados con la ayuda del software ATLAS.ti.

Resultados:

la muestra final seleccionada compuesta por 23 estudios, que fueron agrupados en dos ejes: estrategias y recomendaciones. Cuatro artículos se encuadraron en el eje de “estrategias”, y reportaron acciones adoptadas para afrontar el sufrimiento moral, detallando la intervención y sus resultados. Los demás, incluidos en el eje de “recomendaciones”, son artículos cuyo enfoque fue la experiencia del sufrimiento moral, con sugerencias relacionadas con aspectos importantes para afrontarlo.

Conclusión:

el reconocimiento del sufrimiento moral por parte de los enfermeros y la oportunidad de debate colectivo e intercambio de experiencias son formas de afrontar las situaciones en forma colectiva. Además, se recomendó la participación activa de la institución al implementar las intervenciones. Sin embargo, se percibieron deficiencias en la producción de estudios que, de hecho, profundicen en acciones de intervención para afrontar el sufrimiento moral.

DESCRIPTORES:
Enfermería; Adaptación psicológica; Estrés psicológico; Moral; Ética en enfermería; Hospital

RESUMO

Objetivo:

mapear as evidências científicas sobre estratégias para o enfrentamento do sofrimento moral por enfermeiros no contexto dos serviços de saúde na atenção terciária.

Método:

trata-se de uma Scoping Review com base nas recomendações PRISMA-ScR. As buscas foram realizadas em setembro de 2020 nas bases de dados MEDLINE^®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane e Biblioteca Virtual de Saúde. O critério de elegibilidade foi incluir estudos que discutissem estratégias para o enfrentamento do sofrimento moral pelos enfermeiros na atenção terciária, encontrando assim 2.041 estudos, os quais foram organizados e triados no software Endnote. Os dados foram organizados em planilhas do Excel e uma análise dos resultados foi realizada mediante auxílio do software ATLAS.ti.

Resultados:

a amostra final selecionada foi de 23 estudos, os quais foram agrupados em dois eixos: estratégias e recomendações. Quatro artigos foram enquadrados no eixo “estratégias”, os quais relataram ações realizadas para enfrentamento do sofrimento moral, detalhando a intervenção e os seus resultados. Os demais, incluídos no eixo “recomendações”, são artigos cujo enfoque foi a vivência do sofrimento moral, com sugestão de aspectos importantes para o seu enfrentamento.

Conclusão:

o reconhecimento do sofrimento moral pelos enfermeiros e a oportunidade de discussão coletiva e troca de experiências são formas de enfrentar, coletivamente, as situações. Ademais, foi recomendado a participação ativa da instituição na realização de intervenções. Contudo, perceberam-se lacunas na produção de estudos que de fato aprofundam em ações de intervenções para o enfrentamento do sofrimento moral.

DESCRITORES:
Enfermagem; Adaptação psicológica; Estresse psicológico; Moral; Ética em enfermagem; Hospital

INTRODUCTION

Moral Distress (MD) is a process that can be experienced when nurses are faced with a moral issue, make their judgment, but are unable to act in accordance with their values. In this case, the moral deliberation process is interrupted due to obstacles that prevent the ethical-moral position of the nurse facing the moral issue1.

The MD experience, due to the procedural nature and to its development over time, can lead nurses not to position themselves, which is characterized, by the authors, as “stagnation in uncertainty”1:412. This occurs when the professionals are not able to position themselves according to their ethical-moral values, to morally deliberate and advocate for the patient or to face the moral issue1, developing their practice in a mechanical and uncritical manner, producing invisibilities2.

Specifically in hospitals, the constant experience of moral issues that require the nurses' critical position is perceived. It is noted that the hospital scenario concentrates most of the publications on the theme1, in addition to being an environment permeated by moral issues2. However, it is not always possible for nurses to carry out practices consistent with their moral judgment, affecting quality of health care in these institutions. It is necessary to create ways for nurses to be able to recognize and deal with moral issues in their routine, acting in favor of their practice, that is, patient care2^-3.

National and international studies have focused on analyzing the causes and effects of MD in nurses and state the importance of creating ways to deal with this situation in the researched scenarios1^-2^,4^-7. However, it is fundamental to explore studies that assume interventions focused on coping strategies for MD in hospitals as a research object, given that they can generate positive impacts for the nurse, the institution and the patient.

Given the reality of the cause and effects of the MD experienced by nurses and the importance of coping with it in the hospital setting, the guiding question of this study arises: “which is the scientific evidence on the strategies for coping with MD adopted by nurses in the context of health services in tertiary care?”. This study is justified by the need to map surveys that promote initiatives to face MD, in order to promote the development of ethical practices consistent with the moral judgment of nurses in hospital institutions.

In view of the above, the objective of this study was to map the scientific evidence on strategies for coping with MD adopted by nurses in the context of health services in tertiary care.

METHOD

This is a scoping review, with its protocol registered in the Open Science Framework (OSF) (https://osf.io/962t7). This method allows mapping the main concepts, clarifying research areas and identifying knowledge gaps8, as is the case of intervention strategies for coping with MD.

This review was developed based on the PRISMA-ScR recommendations9 and on the method proposed by the Joanna Briggs Institute10, which establishes five stages: 1) identification of the research question; 2) identification of the relevant studies; 3) selection of the studies; 4) data analysis; and 5) data grouping, synthesis and presentation.

To identify the research question, the PCC strategy was used and, for the purposes of this study: P (Population) - Nurses; C (Concept) - Coping with moral distress; and C (Context) - Health services in tertiary care. Thus, the guiding question was as follows: “which is the scientific evidence on the strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care?”.

The study sample consisted of research studies related to coping strategies for MD adopted by nurses in different services in a hospital context, fully published in the Portuguese, Spanish and/or English languages until August 2020. Editorials, books, letters, monographs, dissertations, theses, blogs, theoretical and reflection articles were excluded.

The search was carried out in September 2020, in the following databases: MEDLINE^®, National Library of Medicine (PubMed); Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (WoS), Cochrane, and Biblioteca Virtual de Saúde (BVS). The strategy adopted was devised with the librarian and the Boolean operators OR and AND were used for each item of the PCC strategy, as described in Chart 1.

Chart 1 -
Definition of search strategies in databases, Belo Horizonte, 2020.

Databases	Search Strategy
BVS	(Nurses OR "Enfermeras y Enfermeros" OR "Enfermeiras e Enfermeiros" OR Enfermeira OR "Enfermeira e Enfermeiro" OR Enfermeiras OR "Enfermeiros Registrados" OR "Nursing, Team" OR "Grupo de Enfermería" OR "Equipe de Enfermagem") AND ("Adaptation, Psychological" OR "Adaptación Psicológica" OR "Adaptação Psicológica" OR "Comportamento Adaptativo" OR "Comportamento de Enfrentamento" OR Enfrentamento OR "Estratégia de Adaptação" OR "Estratégias de Enfrentamento" OR "Habilidades de Enfrentamento" OR "Stress, Psychological" OR "Estrés Psicológico" OR "Estresse Psicológico" OR "Agente de Estresse Psicológico" OR "Estresse Relacionado a Aspectos da Vida" OR "Estresse da Vida" OR "Fatores de Estresse Psicológico" OR "Padecimento Mental" OR "Padecimento Psíquico" OR "Sofrimento Mental" OR "Sofrimento Moral" OR "Sofrimento Psíquico" OR Sofrimentos OR "Tensão Vital" OR "Tensão da Vida" OR Moral OR Morale OR Moral OR "Ethics, Nursing" OR "Ética en Enfermería" OR "Ética em Enfermagem" OR "Ética de Enfermagem") AND ("Health Services" OR "Servicios de Salud" OR "Serviços de Saúde" OR "Consumo de Serviços de Saúde" OR "Rede Prestadora de Serviços de Saúde" OR "Serviços de Atenção ao Paciente" OR "Uso de Serviços de Saúde" OR "Tertiary Healthcare" OR "Atención Terciaria de Salud" OR "Atenção Terciária à Saúde" OR "Atendimento Terciário de Saúde" OR "Atenção Terciária" OR "Atenção Terciária de Saúde" OR "Cuidados Médicos Terciários" OR "Cuidados Terciários de Saúde" OR "Terceiro Nível de Assistência" OR "Terceiro Nível de Atendimento" OR "Terceiro Nível de Atenção" OR "Terceiro Nível de Atenção à Saúde" OR "Terceiro Nível de Cuidado" OR "Terceiro Nível de Cuidados" OR Hospitals OR Hospitales OR Hospitais OR "Centro Hospitalar" OR "Centros Hospitalares" OR Nosocômio OR Nosocômios).
PubMed/ MEDLINE ScopusWeb of Science CINAHL COCHRANE	(Nurses OR "Nursing, Team") AND ("Adaptation, Psychological" OR "Stress, Psychological" OR Moral OR "Ethics, Nursing") AND ("Health Services" OR "Tertiary Healthcare" OR "Hospitals")

The first stage of the review involved searching the databases, in which the articles were identified and exported to the EndNote® software. The studies identified had their titles and abstracts read and analyzed by six reviewers, who worked in pairs, to select the potential eligible articles. In case of disagreement regarding inclusion, a third reviewer performed the assessment.

In the second stage, all the studies included were read in full after development of the first stage by all the reviewers independently in order to answer the review question and extract the data of interest. For this stage, an Excel® software spreadsheet was used, prepared by the authors and organized considering the following variables: author, title, country, year of publication and level of evidence. The doubts generated were resolved by consensus among the authors10. Regarding the results, they were organized, analyzed and categorized using the ATLAS.ti software, version 9. The predefined thematic categories were the following: “strategies” and “recommendations”.

RESULTS

A total of 2,041 articles were identified in the databases and the final sample consisted of 23 studies, as shown in Figure 1.

Figure 1 -
Flowchart referring to the selection process of the Scoping Review studies, adapted from PRISMA-ScR10. Belo Horizonte, MG, Brazil, 2020.

The 23 articles included in this review were organized in a bibliographic chart presented in Chart 2, containing title of the article, country of origin, year of publication, type of study and level of evidence according to the study published in the American Journal of Nursing11.

Chart 2 -
Articles included in the Scoping Review. Belo Horizonte, MG, Brazil, 2020.

Author(s)	Title	Country, year	Type of study, level of evidence
Strategies
Beumer CM12	Innovative solutions: the effect of a workshop on reducing the experience of moral distress in an intensive care unit setting	USA, 2008	Intervention research, level VI
Altounji D, Morgan H, Grover M, Daldumyan S, Secola R13	A Self-Care Retreat for Pediatric Hematology Oncology Nurses	USA, 2013	Experience report, level VI
Leggett JM, Wasson K, Sinacore JM, Gamelli RL14	A pilot study examining moral distress in nurses working in one United States burn center	USA, 2013	Qualitative study, level VI
Abbasi S, Ghafari S, Shahriari M, Shahgholian N15	Effect of moral empowerment program on moral distress in intensive care unit nurses	Iran, 2019	Clinical trial, level II
Recommendations
Akbar RE, Elahi N, Mohammadi E, Khoshknab MF16	What strategies do the nurses apply to cope with job stress?: A Qualitative Study	Iran, 2015	Qualitative study, level VI
Helmers A, Palmer KD, Greenberg RA17	Moral distress: Developing strategies from experience	Canada, 2020	Qualitative and exploratory study, level VI
Schaefer R, Zoboli ELCP, Vieira M18	Moral distress in nurses: A description of the risks for professionals	Brazil, 2018	Quantitative, descriptive and cross-sectional study, level VI
Rodrigues NP, Cohen LL, Swartout KM, Trotochaud K, Murray E19	Burnout in nurses working with youth with chronic pain: A Mixed-Methods Analysis	USA, 2018	Mixed-methods, level VI
Da Luz KR, De Oliveira Vargas MA, Barlem ELD, Schmitt PH, Ramos FRS, Meirelles BHS20	Coping strategies for oncology nurses in high complexity	Brazil, 2016	Qualitative, level VI
Ko HK, Chin CC, Hsu MT21	Moral Distress model reconstructed using grounded theory	China, 2018	Qualitative study, level VI
Langley GC, Kisorio L, Schmollgruber S22	Moral distress experienced by intensive care nurses	South Africa, 2015	Descriptive/Exploratory study, level VI
Bender MA, Andrilla CHA, Sharma RK, Hurd C, Solvang N, Mae-Baldwin L23	Moral Distress and attitudes about timing related to comfort care for hospitalized patients: A survey of inpatient providers and Nurses	USA, 2019	Cross-sectional study, level VI
Christodoulou-Fella M, Middleton N, Papathanassoglou ED, Karanikola MN24	Exploration of the association between nurses’ moral distress and secondary traumatic stress syndrome: Implications for patient safety in mental health services	Cyprus, 2017	Cross-sectional study, level VI
Wenwen Z, Xiaoyan W, Yufang Z, Lifeng C, Congcong S25	Moral distress and its influencing factors: A cross-sectional study in China	China, 2018	Cross-sectional study, level VI
Hamaideh SH26	Moral distress and its correlates among mental health nurses in Jordan	Jordan, 2014	Cross-sectional study, level VI
Ghasemi E, Negarandeh R, Janani L27	Moral distress in Iranian pediatric nurses	Iran, 2019	Cross-sectional study, level VI
Barlem ELD, Lunardi VL, Lunardi GL, Tomaschewski-Barlem JG, Silveira RSD, Dalmolin GDL28	Moral distress in nursing personnel	Brazil, 2013	Quantitative, survey-type, exploratory-descriptive and cross-sectional research study, level IV
Morley G29	Efficacy of the nurse ethicist in reducing moral distress: what can the NHS learn from the USA? Part 2	England, 2016	Literature review, level V
Ohnishi K, Kitaoka K, Nakahara J, Välimäki M, Kontio R, Anttila M30	Impact of moral sensitivity on moral distress among psychiatric nurses	Finland, 2019	Cross-sectional study, level VI
Schaefer R, Vieira M31	Ethical competence as a coping resource for moral distress in nursing	Brazil, 2015	Integrative literature review, level V
Edmonson C32	Strengthening Moral Courage among nurse leaders	USA, 2015	Review, level V
Schluter J, Winch S, Holzhauser K, Henderson A33	Nurses: moral sensitivity and hospital ethical climate: a literature review	USA, 2008	Literature review of quantitative and qualitative studies, level V
Dalmolin GDL, Lunardi VL, Lunardi GL, Barlem ELD, Silveira RSD34	Nurses, nursing technicians and assistants: Who experiences more moral distress?	Brazil, 2014	Qualitative research, level VI

As shown in Chart 2, the articles were grouped into two categories, namely: strategies (04 articles) and recommendations (19 articles).

Regarding the articles included in the “strategies” category, they reported actions taken to cope with MD, detailing the intervention, the evaluation modality and its results (Figure 2).

Figure 2 -
Strategies for coping with MD, Belo Horizonte, MG, Brazil, 2020.

Regarding the types of strategies, the three emphasized development of the recognition of MD by the nurses and the opportunity for discussion and exchange of experiences among the participants, thus creating together ways to face the situation. In addition, it was noticed that, of the four interventions, three applied MD scales for pre- and post-action assessment. The institution's role in carrying out the interventions is highlighted, as it is responsible for their execution.

The articles included in the “recommendations” category, on the other hand, are those whose focus was the MD experience, and the coping strategies were only recommendations/suggestions, that is, there were no detailed interventions throughout the article. Among the coded recommendations/suggestions, it was noticed that 14 articles addressed the importance of spaces for discussion and exchange of experiences among the team16^-17^,20^-23^,25^-29^,31^,34; nine addressed the team's collaboration in this coping16^,17^,19^,22^-25^,33^,34, the need for education and development of ethical skills17^,20^-24^,27^-29 and institutional and leadership support16^,26^-32^,34; eight mentioned the implementation of moral strengthening programs and support for the ethical climate17^,23^-24^,26^-29^,31^,34; six dealt with the need for the professionals to recognize the causes of MD17^-18^,21^,24^,28^-29; five disclosed the importance of promoting autonomy, self-reflection, self-awareness and self-confidence16^-17^,22^,24^-25; three mentioned welcoming and emotional support to the professionals in the face of MD16^,24^,26 and dealt with resilience and moral courage17^,27^,32; two discussed the construction of healthy work environments26^,30 and the creation of programs for recreational activities/sports and spiritual support16^-17; and one article referred to the influence of adequate staffing.

In general, the results showed that the intervention strategies adopted encompass the relevance of MD recognition for coping with it; the need to deal with the situation collectively, sharing experiences; and the importance of institutional responsibility in adopting measures to face MD.

DISCUSSION

MD recognition by nurses in the practice environment was the focus of the actions to cope with MD in the eligible studies. In the description of these actions, the concept and signs and symptoms of MD were addressed, as well as the barriers that prevent decision-making in consonance with the professionals' moral judgment and the exchange of experiences among the team members to deal with moral issues.

When outlining coping strategies, it becomes necessary that those who experience MD understand its concept. MD is triggered when the professionals are faced with a moral issue, make their moral judgment, but are prevented from making a decision due to barriers that can be influenced by gender, ethnicity, lack of time, organizational and institutional policies, work environment and the contradiction between the idealized practice and its performance in the work routine2^,35. It is an individual moral experience, in which each professional experiences distress differently1.

When experiencing MD, the professional experiences a feeling of frustration, anguish, loss of autonomy and, thus, impotence to act, producing invisibilities2. Such invisibility distances nurses from their practice, causing identity ruptures, insecurities and loss of meaning, which may culminate in job abandonment2. Given such feelings, recognition of MD becomes necessary, which occurs through moral sensitivity, being the starting point for coping with it.

Moral sensitivity is an important skill for Nursing in making moral decisions and managing ethical problems in the different health care spaces36. Development of sensitivity can take place through ethical Nursing education, professional experience, clinical knowledge, dialog, relationship with the other members of the health team and professional autonomy3^,36. Such components promote the construction of new moral skills that will assist these individuals in recognizing MD and its experience7. Thus, they will be able to objectively outline individual and collective strategies for coping with it.

Regarding the provision of collective spaces for coping with MD, the ethical discussion among those involved stands out as indispensable, where there is exposure of moral anguish, which is highly subjective, making it possible to map situations that are ethically challenging and potential generators of MD27. For this to occur, it becomes necessary for the individual to establish effective and horizontal communication with the team, providing opportunities for group analysis of the situations in order to contribute to decision-making in accordance with their moral judgment37^-38.

The interventions in this review showed the importance of listening to the feelings and promoting mutual accountability for the decisions made in the workplace39. Through these actions, nurses feel welcomed and are able to develop individual and team action plans focused on self-care and professional empowerment, contributing to coping with MD12^,15^,40. Such actions can be developed in collective spaces, such as formal or informal meetings, in order to promote a safe and participatory environment for questions, reflections and analyses of everyday ethical situations, so that the workers can share experiences, feelings and knowledge3^,40. In addition, the results of this review pointed to the conduction of meetings such as workshops, retreats and educational interventions in groups.

It is noteworthy that these spaces provide opportunities for discussions, dialog, exchange of experiences, sharing of knowledge and feelings and team collaboration. In this context, the collaborative practice is revealed, which is based on the interdisciplinary work that recognizes the role and knowledge of each professional within the team41. This practice promotes autonomy, trust, empowerment and better performance of activities, impacting on the optimization of the interprofessional relationships and shared decision-making among those involved39. This is because it encompasses an intense process of reflection and exchange of experience among the subjects, considering the moral judgment of each one. The collaborative practice reveals itself, then, as a powerful protective factor against the MD experiences, since it turns moral deliberation into a collective act39.

It is therefore understood that collaborative practice must be adopted as an institutional culture, in which the presence and support of leaders, horizontalized work relationships and integration between the different professionals are encouraged in order to create co-accountability among the actors involved by the processes faced in the work routine, including MD. It is important that collaborative practice is assumed as an institutional value, being a guide for the professionals' moral deliberation.

In this context, institutional responsibility in dealing with MD stands out. This research evidenced the importance of adopting institutional strategies that prioritize measures to deal with MD in the work environment, which promotes healthy work environments. A study conducted during the pandemic42 found that there is a reciprocal and bilateral relationship between MD and the dimensions of the Healthy Work Environment (HWE) proposed by the WHO41. This relationship is presented in how values underlying the two constructs are affected, with the possibility of compromising the structures of the work environment and the workers' well-being. And articulating them has the power to promote insights for interventions that protect the workers from MD experiences42.

Healthy work environment promotion programs help institutions protect and promote the health of their workforce, integrating health, safety and well-being into a process of constant improvements43, through a mutual commitment between workers and managers, in a collaborative manner41. Thus, the commitment to promoting healthy work environments includes concern with psychosocial and organizational aspects, such as organizational culture, attitudes, values, beliefs, spirituality and daily practices, which exert an influence on the workers' mental and physical well-being41 and, therefore, prevent MD experiences. On the other hand, mismatches between the management and organization practices negatively affect the workers' psychological, social and physical aspects44. In this sense, as a way of providing a healthy psychosocial environment and minimizing MD experiences, it is recommended to implement proper distribution and reduction of workload, provision of communication and leadership training for managers, zero tolerance for harassment and discrimination in the workplace, as well as a management style that promotes consultation, negotiations, reciprocal communication, constructive feedback and respectful performance management41^,45.

It is reinforced that the interventions for coping with MD need to be incorporated as an institutional responsibility, providing, in addition to development of moral sensitivity for its recognition by the parties, individual and collective engagement in the deliberations involving moral issues in the routine practice of nurses in institutions and promotion of healthy work environments.

This study presents limitations referring to the descriptors defined in the search strategy. This is because there is no specific descriptor for “moral distress”, which represents low sensitivity in the search for studies that answered the research question. In this sense, many studies were identified and subsequently excluded in the screening stage for addressing issues such as mental distress and burnout. In addition, the absence of research studies with level of evidence I, systematic reviews or meta-analysis in the study sample is highlighted. However, this is justified due to the existing scientific gap and lack of intervention research studies aimed at coping with MD.

The contributions to the field of Nursing are based on the impact caused by MD on nurses, both personally and professionally. Thus, studies like this, which explore interventions for coping with MD in hospitals, encourage the adoption of actions that foster the development of ethical practices consistent with the nurses' moral judgment, favoring a healthy work environment and the quality of the Nursing care provided.

CONCLUSION

This study mapped the diverse scientific evidence on strategies for coping with MD adopted by nurses in the context of health services in tertiary care. The sample consisted of 23 studies that pointed out, among strategies and recommendations for coping with moral distress, the importance that such coping be carried out collectively by the team, highlighting the opportunity for meetings and spaces for discussion to exchange experiences that lead to the recognition of moral distress, its signs and symptoms and co-accountability between the parties involved and the institution in the process of coping with MD.

It is important to emphasize that, although the hospital context concentrates most of the publications about moral distress in the literature, we notice that, among the 23 studies, only 4 articles adopted interventions focused on coping strategies for MD in hospitals as research object; the rest (19 articles) focused on the MD experience, addressing recommendations/suggestions of relevant aspects in their work, not detailing any action in itself. Therefore, the scarcity of studies in the literature addressing intervention actions to cope with MD is highlighted, which is a suggestion for developing new studies in this area.

ACKNOWLEDGMENT

Universidade Federal de Minas Gerais (UFMG).

REFERENCES

• 1. Ramos FR, Barth PO, Brito MJ, Caram C, Silveira LR, Brehmer LC, Dalmolin GL, Caçador B. Sociodemographic and work-related aspects of moral distress in Brazilian nurses. Acta Paul Enferm [Internet]. 2019 [cited 2021 Jan 28];32(4):406-15. Available from: Available from: https://doi.org/10.1590/1982-0194201900056
  » https://doi.org/10.1590/1982-0194201900056
• 2. Caram CS, Peter E, Brito MJ. Invisibility of the self: Reaching for the telos of nursing within a context of moral distress. Nurs Inq [Internet]. 2019 [cited 2021 Jan 28];26(1):e12269. Available from: Available from: https://doi.org/10.1111/nin.12269
  » https://doi.org/10.1111/nin.12269
• 3. Tomaschewisk-Barlem JG, Schallenberger CD, Ramos-Toescher AM, Barlem ELD, Rocha LP, Castanheira JS. Strategies to develop moral sensitivity: a perspective of intensive care unit nurses. Esc Anna Nery [Internet]. 2020 [cited 2021 Jan 28];24(3):e20190311. Available from: Available from: https://doi.org/10.1590/2177-9465-ean-2019-0311
  » https://doi.org/10.1590/2177-9465-ean-2019-0311
• 4. Woods M. Moral distress revisited: the viewpoints and responses of nurses. Int Nurs Rev [Internet]. 2020 [cited 2021 Jan 28];67(1):68-75. Available from: Available from: https://doi.org/10.1111/inr.12545
  » https://doi.org/10.1111/inr.12545
• 5. Arnold TC. Moral distress in emergency and critical care nurses: A metaethnography. Nurs Ethics [Internet]. 2020 [cited 2021 Jan 28];27(8):1681-93. Available from: Available from: https://doi.org/10.1177/0969733020935952
  » https://doi.org/10.1177/0969733020935952
• 6. Pereira VT, Oliveira MAN, Fontoura EG, Servo ML, Freitas KS, Portela PP, Góis JA. Sofrimento moral vivenciado pelo enfermeiro em unidade de terapia intensiva neonatal. Braz J Hea Rev [Internet]. 2020 [cited 2021 Jan 28];3(4):7590-602. Available from: Available from: https://doi.org/10.34119/bjhrv3n4-032
  » https://doi.org/10.34119/bjhrv3n4-032
• 7. Schallenberger CD, Tomaschewski-Barlem JG, Barlem ELD, Rocha LP, Dalmolin GL, Pereira LA. Moral sensitivity components identified among nurses from Intensive Care Units. Rev Bras Enferm [Internet]. 2019 [cited 2021 Jan 28];72(Suppl 1):2-8. Available from: Available from: https://doi.org/10.1590/0034-7167-2017-0202
  » https://doi.org/10.1590/0034-7167-2017-0202
• 8. Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. The role of public health managers in a border region: a scoping review. Acta Paul Enferm [Internet]. 2019 [cited 2021 Jan 28];32(2):229-36. Available from: Available from: https://doi.org/10.1590/1982-0194201900031
  » https://doi.org/10.1590/1982-0194201900031
• 9. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z, eds. JBI Manual for evidence synthesis [Internet]. 2020 [cited 2021 Jan 28]. Available from: Available from: https://doi.org/10.46658/jbimes-20-12
  » https://doi.org/10.46658/jbimes-20-12
• 10. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med [Internet]. 2018 [cited 2021 Jan 28];169(7):467-73. Available from: Available from: https://doi.org/10.7326/M18-0850
  » https://doi.org/10.7326/M18-0850
• 11. Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. Am J Nurs [Internet]. 2010 [cited 2021 Jan 28];110(1):51-3. Available from: Available from: https://doi.org/10.1097/01.naj.0000366056.06605.d2
  » https://doi.org/10.1097/01.naj.0000366056.06605.d2
• 12. Beumer CM. Innovative solutions: The effect of a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimens Crit Care Nurs [Internet]. 2008 [cited 2021 Jan 28];27(6):263-7. Available from: Available from: https://doi.org/10.1097/01.DCC.0000338871.77658.03
  » https://doi.org/10.1097/01.DCC.0000338871.77658.03
• 13. Altounji D, Morgan H, Grover M, Daldumyan S, Secola R. A self-care retreat for pediatric hematology oncology nurses. J Pediatr Oncol Nurs [Internet]. 2013 [cited 2021 Jan 28];30(1):18-23. Available from: Available from: https://doi.org/10.1177/1043454212461951
  » https://doi.org/10.1177/1043454212461951
• 14. Leggett JM, Wasson K, Sinacore JM, Gamelli RL. A pilot study examining moral distress in nurses working in one United States burn center. J Burn Care Res [Internet]. 2013 [cited 2021 Jan 28];34(5):521-8. Available from: Available from: https://doi.org/10.1097/bcr.0b013e31828c7397
  » https://doi.org/10.1097/bcr.0b013e31828c7397
• 15. Abbasi S, Ghafari S, Shahriari M, Shahgholian N. Effect of moral empowerment program on moral distress in intensive care unit nurses. Nurs Ethics [Internet]. 2019 [cited 2021 Jan 28];26(5):1494-504. Available from: Available from: https://doi.org/10.1177/0969733018766576
  » https://doi.org/10.1177/0969733018766576
• 16. Eslami Akbar R, Elahi N, Mohammadi E, Fallahi Khoshknab M. What Strategies Do the Nurses Apply to Cope With Job Stress?: A Qualitative Study. Glob J Health Sci [Internet]. 2015 [cited 2021 Jan 28];8(6):55-64. Available from: Available from: https://doi.org/10.5539/gjhs.v8n6p55
  » https://doi.org/10.5539/gjhs.v8n6p55
• 17. Helmers A, Palmer KD, Greenberg RA. Moral distress: Developing strategies from experience. Nurs Ethics [Internet]. 2020 [cited 2021 Jan 28];27(4):1147-56. Available from: Available from: https://doi.org/10.1177/0969733020906593
  » https://doi.org/10.1177/0969733020906593
• 18. Schaefer R, Zoboli ELCP, Vieira M. Moral distress in nurses: a description of the risks for professionals. Texto Contexto Enferm [Internet]. 2018 [cited 2021 Jan 28];27(4):e4020017. Available from: Available from: https://doi.org/10.1590/0104-07072018004020017
  » https://doi.org/10.1590/0104-07072018004020017
• 19. Rodrigues NP, Cohen LL, Swartout KM, Trotochaud K, Murray E. Burnout in Nurses Working With Youth With Chronic Pain: A Mixed-Methods Analysis. J Pediatr Psychol [Internet]. 2018 [cited 2021 Jan 28];43(4):369-81. Available from: Available from: https://doi.org/10.1093/jpepsy/jsx105
  » https://doi.org/10.1093/jpepsy/jsx105
• 20. Da Luz KR, de Oliveira Vargas MA, Barlem ELD, Schmitt PH, Ramos FRS, Meirelles BHS. Coping strategies for oncology nurses in high complexity. Rev Bras Enferm [Internet]. 2016 [cited 2021 Jan 28];69(1):59-63. Available from: Available from: https://doi.org/10.1590/0034-7167.2016690109i
  » https://doi.org/10.1590/0034-7167.2016690109i
• 21. Ko HK, Chin CC, Hsu MT. Moral distress model reconstructed using grounded theory. J Nurs Res [Internet]. 2018 [cited 2021 Jan 28];26(1):18-26. Available from: Available from: https://doi.org/10.1097/JNR.0000000000000189
  » https://doi.org/10.1097/JNR.0000000000000189
• 22. Langley GC, Kisorio L, & Schmollgruber S. Moral distress experienced by intensive care nurses. Southern African Journal of Critical Care [Internet]. 2015 [cited 2021 Jan 28];31(2):36-41. Available from: Available from: https://doi.org/10.7196/SAJCC.2015.v31i2.235
  » https://doi.org/10.7196/SAJCC.2015.v31i2.235
• 23. Bender MA, Andrilla CHA, Sharma RK, Hurd C, Solvang N, Mae-Baldwin L. Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses. Am J Hosp Palliat Care [Internet]. 2019 [cited 2021 Jan 28];36(11):967-73. Available from: Available from: https://doi.org/10.1177/1049909119843136
  » https://doi.org/10.1177/1049909119843136
• 24. Christodoulou-Fella M, Middleton N, Papathanassoglou EDE, Karanikola MNK. Exploration of the Association between Nurses' Moral Distress and Secondary Traumatic Stress Syndrome: Implications for Patient Safety in Mental Health Services. Biomed Res Int [Internet]. 2017 [cited 2021 Jan 28];2017:1908712. Available from: Available from: https://doi.org/10.1155/2017/1908712
  » https://doi.org/10.1155/2017/1908712
• 25. Wenwen Z, Xiaoyan W, Yufang Z, Lifeng C, Congcong S. Moral distress and its influencing factors: A cross-sectional study in China. Nurs Ethics [Internet]. 2018 [cited 2021 Jan 28];25(4):470-80. Available from: Available from: https://doi.org/10.1177/0969733016658792
  » https://doi.org/10.1177/0969733016658792
• 26. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs [Internet]. 2014 [cited 2021 Jan 28];23(1):33-41. Available from: Available from: https://doi.org/10.1111/inm.12000
  » https://doi.org/10.1111/inm.12000
• 27. Ghasemi E, Negarandeh R, Janani L. Moral distress in Iranian pediatric nurses. Nurs Ethics [Internet]. 2019 [cited 2021 Jan 28];26(3):663-73. Available from: Available from: https://doi.org/10.1177/0969733017722824
  » https://doi.org/10.1177/0969733017722824
• 28. Barlem EL, Lunardi VL, Lunardi GL, Tomaschewski-Barlem JG, da Silveira RS, Dalmolin GL. Moral distress in nursing personnel. Rev Lat Am Enfermagem [Internet]. 2013 [cited 2021 Jan 28];21(Spe):79-87. Available from: Available from: https://doi.org/10.1590/s0104-11692013000700011
  » https://doi.org/10.1590/s0104-11692013000700011
• 29. Morley G. Efficacy of the nurse ethicist in reducing moral distress: what can the NHS learn from the USA? Part 2. Br J Nurs [Internet]. 2016 [cited 2021 Jan 28];25(3):156-61. Available from: Available from: https://doi.org/10.12968/bjon.2016.25.3.156
  » https://doi.org/10.12968/bjon.2016.25.3.156
• 30. Ohnishi K, Kitaoka K, Nakahara J, Välimäki M, Kontio R, Anttila M. Impact of moral sensitivity on moral distress among psychiatric nurses. Nurs Ethics [Internet]. 2019 [cited 2021 Jan 28];26(5):1473-83. Available from: Available from: https://doi.org/10.1177/0969733017751264
  » https://doi.org/10.1177/0969733017751264
• 31. Schaefer R, Vieira M. Ethical competence as a coping resource for moral distress in nursing. Texto Contexto Enferm [Internet]. 2015 [cited 2021 Jan 28];24(2):563-73. Available from: Available from: https://doi.org/10.1590/0104-07072015001032014
  » https://doi.org/10.1590/0104-07072015001032014
• 32. Edmonson C. Strengthening Moral Courage Among Nurse Leaders. Online J Issues Nurs [Internet]. 2015 [cited 2021 Jan 28];20(2):9. Available from: Available from: https://doi.org/10.3912/ojin.vol20no02ppt01
  » https://doi.org/10.3912/ojin.vol20no02ppt01
• 33. Schluter J, Winch S, Holzhauser K, Henderson A. Nurses' moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics [Internet]. 2008 [cited 2021 Jan 28];15(3):304-21. Available from: Available from: https://doi.org/10.1177/0969733007088357
  » https://doi.org/10.1177/0969733007088357
• 34. Dalmolin GDL, Lunardi VL, Lunardi GL, Barlem ELD, Silveira RSD. Nurses, nursing technicians and assistants: who experiences more moral distress? Rev Esc Enferm USP [Internet]. 2014 [cited 2021 Jan 28];48(3):521-9 Available from: Available from: https://doi.org/10.1590/S0080-623420140000300019
  » https://doi.org/10.1590/S0080-623420140000300019
• 35. Greco PBT, Bernardi CMS, Balbueno BL, Machado LM, Magnago TSBS, Dalmolin GL. Moral distress in workers Nursing of a philanthropic hospital. Research, Society and Development [Internet]. 2020 [cited 2021 Jan 28];9(8):e111985391. Available from: Available from: https://doi.org/10.33448/rsd-v9i8.5391
  » https://doi.org/10.33448/rsd-v9i8.5391
• 36. Borhani F, Abbaszadeh A, Mohamadi E, Ghasemi E, Hoseinabad-Farahani MJ. Moral sensitivity and moral distress in Iranian critical care nurses. Nurs Ethics [Internet]. 2017 [cited 2021 Jan 28];24(4):474-82. Available from: Available from: https://doi.org/10.1177/0969733015604700
  » https://doi.org/10.1177/0969733015604700
• 37. Wocial L, Ackerman V, Leland B, Benneyworth B, Patel V, Tong Y, Nitu M. Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU. HEC Forum [Internet]. 2017 [cited 2021 Jan 28];29(1):75-91. Available from: Available from: https://doi.org/10.1007/s10730-016-9313-0
  » https://doi.org/10.1007/s10730-016-9313-0
• 38. Barlem ELD, Lunardi VL, Lunardi GL, Tomaschewski-Barlem JG, Silveira RSD, Dalmolin GDL. Moral distress in nursing personnel. Rev Latino Am Enferm [Internet]. 2013 [cited 2021 Jan 28];21(Spe):79-87. Available from: Available from: https://doi.org/10.1590/S0104-11692013000700011
  » https://doi.org/10.1590/S0104-11692013000700011
• 39. Caram CS, Rezende LC, Brito MJM. Collaborative practice: potentialities and challenges for nurses in the hospital context. Rev Min Enferm [Internet]. 2017 [cited 2021 Jan 28];21:e-1070. Available from: Available from: https://doi.org/10.5935/1415-2762.20170080
  » https://doi.org/10.5935/1415-2762.20170080
• 40. Lamb FA, Beck CLC, Coelho APF, Vasconcelos RO. Nursing work in a pediatric emergency service: between pleasure and pain. Cogitare Enferm [Internet]. 2019 [cited 2021 Jan 28];24:e59396. Available from: Available from: https://doi.org/10.5380/ce.v24i0.59396
  » https://doi.org/10.5380/ce.v24i0.59396
• 41. World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva (CH): World Health Organization; 2010. [cited 2021 Jan 28]. Available from: Available from: https://hsc.unm.edu/ipe/resources/who.html
  » https://hsc.unm.edu/ipe/resources/who.html
• 42. Caram CS, Ramos FRS, Almeida NG, Brito MJM. Moral suffering in health professionals: portrait of the work environment in times of COVID-19. Rev Bras Enferm [Internet]. 2021 [cited 2021 Sep 16];74(Suppl 1):e20200653. Available from: Available from: https://doi.org/10.1590/0034-7167-2020-0653
  » https://doi.org/10.1590/0034-7167-2020-0653
• 43. Pham CT, Lee CB, Nguyen TLH, Lin JD, Ali S, Chu C. Integrative settings approach to workplace health promotion to address contemporary challenges for worker health in the Asia-Pacific. Glob Health Promot [Internet]. 2019 [cited 2021 Jan 28];27(2):8290. Available from: Available from: https://doi.org/10.1177/1757975918816691
  » https://doi.org/10.1177/1757975918816691
• 44. Rodrigues CML, Faiad C. Pesquisa sobre riscos psicossociais no trabalho: Estudo bibliométrico da produção nacional de 2008 a 2017. Rev Psicol Organ Trab [Internet]. 2019 [cited 2021 May 13];19(1):571-9. Available from: Available from: https://doi.org/10.17652/rpot/2019.1.15424
  » https://doi.org/10.17652/rpot/2019.1.15424
• 45. Pimenta CJL, Viana LRDC, Bezerra TA, Silva CRRD, Costa TFD, Costa KNDFM. Pleasure, suffering and interpersonal communication in the work of nurses in the hospital setting. Texto Contexto Enferm [Internet]. 2020 [cited 2021 May 09];29:e20190039. Available from: Available from: https://doi.org/10.1590/1980-265x-tce-2019-0039
  » https://doi.org/10.1590/1980-265x-tce-2019-0039

NOTES

• FUNDING INFORMATION

  Pró-Reitoria de Pesquisa da UFMG (PRPQ: 09-2019).

Edited by

EDITORS

Associated Editors: Gisele Cristina Manfrini, Monica Motta Lino. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  11 Feb 2022
• Date of issue
  2022

History

• Received
  14 May 2021
• Accepted
  23 Sept 2021