Assessment of Moral Distress in Respiratory Therapists Open Access

Timmer, Marjorie (2014)

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Moral distress (Md) is the psychological disequilibrium experienced when one perceives the right moral action to take but is constrained from taking that action. Only one study has focused specifically on Md among respiratory therapists (RTs). Research demonstrates a correlation between Md and perception of workplace ethical climate (PEC). It is important to study this problem in all health care workers (HCWs) because, left unaddressed, Md may result in adverse emotional and physical symptoms, increased risk of burnout, and loss of HCWs from the workforce. Existing surveys may underestimate Md in non-nursing HCWs.

Five RT-specific survey items were designed for and administered to RTs along with a validated Md instrument (MDS-R) that has been utilized in nursing research. Survey reliability was assessed with calculation of Cronbach's alpha. Statistical analyses were performed on 1) moral distress index (MdI) measured with and without RT-specific survey items; 2) MdI in RTs who had left or considered leaving a clinical position because of Md versus RTs who had not done so; and 3) the relationship between Md and the PEC.

Cronbach's alpha was 0.898. Two of the five RT-specific Md survey items demonstrated construct validity with two recent studies in RTs. The MdI measured using the revised survey was significantly higher than that from the MDS-R alone (r = .982, p < 0.001). The MdI was significantly higher in RTs who had ever left or considered leaving a position because of their Md than in those who had never done so (p < .021); and among those currently planning versus not planning leave a position (p < 0.001). There was a negative correlation (-0.423) between Md and PEC.

The data supported the hypothesis that augmenting a generic survey with a limited number of discipline-specific items optimized Md assessment in RTs. Correlations reported elsewhere of job attrition and PEC with Md are replicated in this study.

Validation of new survey items should continue. Other HC disciplines are encouraged to develop discipline-specific Md survey items for their constituencies. End-of-life education for RTs and their colleagues is recommended.

Table of Contents

Table of Contents

Chapter One - Study description 1

Introduction 1

Respiratory therapists 1

Moral distress 3

Moral uncertainty, moral dilemma vs. moral distress 4

Root causes of moral distress 4

The "medical hierarchy" 5

End of life care 9

Inappropriate use of resources 10

Conclusion 10

Research questions 11

Chapter Two - Literature review 12

Introduction 12

Defining moral distress 12

Root causes of moral distress 15

Clinical situations 16

External constraints 16

Internal constraints 17

Perception and powerlessness 18

Initial and reactive moral distress 19

Measurement of moral distress 21

M L Raines 21

M C Corley 21

A B Hamric 22

Wocial and Weaver 23

Workplace ethical climate 24

Relationship between moral distress and workplace ethical climate 25

Moral distress in RTs 27

Caplan et al 28

Schwenzer and Wang 30

Allen et al 31

Houston et al 32

Respiratory therapy, moral distress and the Sentimentalist moral theory 33

Professional boundaries 35

RTs and end-of-life care 37

Conclusion 40

Chapter Three - Study Methods 45

Introduction 45

Study methods summary 46

Supplement vs. replace MDS-R 47

Survey development 49

Pilot studies 50

Rationale for survey items 54

Preparations for initiating the survey 58

Data collection 58

Statistical analysis 60

Cronbach's alpha 60

Covariance and correlations 61

Chapter Four - Results 63

Introduction 63

Description of data and statistical tests 63

Cronbach's alpha 64

Descriptive data 64

Comparisons of moral distress index 67

Moral distress vs. intent to leave a position 67

Correlation with workplace ethical climate 69

Answers to research questions 70

Research question #1 70

Research question #2 70

Research question #3 72

Summary of results 75

Chapter Five - Conclusions and Next Steps 87

Introduction 87

Research question #1 87

Research question #2 90

Research question #3 91

Other data 92

Moral Distress and Perception of Workplace Ethical Climate 92

Moral Distress and the Intent to Leave a Clinical Position 92

Conclusion 93

Recommendations for future research 93

Bibliography 96

Non-print citations 102



Table 2.1. Corley's moral distress factors 22

Table 2.2. Root causes of Moral Distress 42

Table 2.3. Most common sources of moral distress - Schwenzer and Wang 43

Table 2.4. Most common causes of moral distress - Allen et al (2013) 44

Table 3.1. Situations causing moral distress to RTs 50

Table 3.2. Characteristics of pilot participants 51

Table 3.3. Survey distribution 60

Table 4.1. Reliability statistics 76

Table 4.2. Demographic data 64

Table 4.3. Respondents' education 66

Table 4.4. Professional credentials 66

Table 4.5. Hospital type and size 66

Table 4.6. Moral distress score rankings 79

Table 4.7. Moral Distress Index 67

Table 4.8. Moral distress and intent to leave a clinical position 68

Table 4.9. RN, MD, and RT moral distress index comparisons 85

Table 4.10. RT attitudes about terminal extubation 86

Table 5.1. Moral distress sources - comparison to RN studies 95

Table 5.2. Comparisons of moral distress index: Hamric & Corley vs. study data 89


Figure 2.1. Moral distress index and number of respondents (Allen et al 2013) 43

Figure 4.1. RT age vs. moral distress 65

Figure 4.2. Scatterplot of moral distress vs. PEC scores 69

Figure 4.3. Moral distress, ethical climate and intent or actual decision to resign 77

Figure 4.4. Moral distress, PEC vs. intention to leave 78


Moral distress survey: MDS-R, HECS, RT-specific items, Appendix A

and demographic items

Institutional Review Board Letter, July 26, 2013 Appendix B

Institutional Review Board Letter, May 15, 2013 Appendix C

Permission letter via email from Ann Hamric, PhD, RN, FAAN Appendix D

Confirmation of permission via email from A. Hamric Appendix E

Permission letter via email from Linda Olson, PhD, MBA, RN, NEA-BC Appendix F

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