Background

Moral distress is a pervasive phenomenon that can negatively impact healthcare professionals and has been well studied in nursing populations. Much of the evidence suggests that it is associated with intention to leave high acuity areas and the profession. Despite the increasing amounts of research to explore the causes and effects of moral distress, there is limited research on interventions that mitigate the negative effects of moral distress.

Objectives

The aims of this systematic review were to: (a) identify and examine interventions developed to address moral distress experienced by health care professionals (b) examine the quality of the research methods and (c) report on the efficacy of these interventions.

Design

We conducted a systematic review of interventional studies developed to mitigate moral distress.

Data Source

Medline, Embase, PsycINFO, CINAHL and Cochrane were searched for relevant studies (July 2019- September 2019). Additional bioethics databases and reference lists were also hand-searched.

Review methods

The first author reviewed all retrieved titles and abstracts with a low tolerance for borderline papers based on inclusion and exclusion criteria, and those papers were reviewed and discussed by all authors to determine inclusion. Quality appraisal was conducted on the included studies using narrative synthesis to compare the findings. Data were extracted and compared by all authors and then reviewed by the first author for consistency.

Results

Sixteen papers were included for full text review and the following interventions identified: educational interventions of varying length and breadth; facilitated discussions ranging from 30 to 60 minutes; specialist consultation services; an intervention bundle; multidisciplinary rounds; self-reflection and narrative writing. Researchers reported statistically significant reductions in moral distress using pre and post surveys, including one mixed methods program evaluation (n=7). The qualitative program evaluation provided participant quotations to suggest their program was beneficial. There were no statistically significant findings in the other studies (n=8). All studies had limitations in design and methodology presenting significant threats to validity.

Conclusion

Designing rigorous research studies that measure the impact of interventions aimed at mitigating moral distress continues to be challenging. The primary reason being that moral distress is a subjective ethical phenomenon with a number of different causes and effects. This calls for interventions that are flexible and sensitive to individual's needs. To build an evidence-base, interventions should also be measurable and research methods need to be scientifically rigorous. To achieve rigor and innovation, researchers should clearly justify their methodological choices.

Tweetable abstract: Interventions to mitigate moral distress: a systematic review of the literature. Educational interventions offer a promising direction but more research is needed.

中文翻译：

---

减轻道德困扰的干预措施：文献的系统回顾

背景

道德困扰是一种普遍现象，会对医疗保健专业人员产生负面影响，并且在护理人群中得到了很好的研究。许多证据表明，这与离开高敏锐度领域和职业的意图有关。尽管探索道德困扰的原因和影响的研究越来越多，但对减轻道德困扰的负面影响的干预措施的研究有限。

目标

本系统评价的目的是：(a) 确定和检查为解决卫生保健专业人员所经历的道德困境而制定的干预措施 (b) 检查研究方法的质量和 (c) 报告这些干预措施的有效性。

设计

我们对旨在减轻道德困扰的干预研究进行了系统评价。

数据源

检索了 Medline、Embase、PsycINFO、CINAHL 和 Cochrane 的相关研究（2019 年 7 月-2019 年 9 月）。还手动搜索了其他生物伦理学数据库和参考列表。

复习方法

第一作者根据纳入和排除标准审查了所有检索到的对边缘论文具有低容忍度的标题和摘要，所有作者对这些论文进行了审查和讨论以确定纳入。使用叙事合成对纳入的研究进行质量评估，以比较结果。数据由所有作者提取和比较，然后由第一作者审查以确保一致性。

结果

16 篇论文被纳入全文审查，并确定了以下干预措施： 不同长度和广度的教育干预措施；促进了 30 到 60 分钟的讨论；专家咨询服务；干预包；多学科轮次；自我反思和叙事写作。研究人员报告说，使用前后调查，包括一种混合方法程序评估（n = 7），道德困境在统计学上显着减少。定性计划评估提供了参与者的报价，以表明他们的计划是有益的。在其他研究（n=8）中没有统计学意义的发现。所有研究在设计和方法上都有局限性，这对有效性构成了重大威胁。

结论

设计严格的研究来衡量旨在减轻道德困扰的干预措施的影响仍然具有挑战性。主要原因是道德困境是一种主观的伦理现象，具有多种不同的因果关系。这需要对个人需求灵活且敏感的干预措施。为了建立证据基础，干预措施也应该是可衡量的，研究方法需要科学严谨。为了实现严谨和创新，研究人员应该清楚地证明他们的方法选择是合理的。

Tweetable 摘要：减轻道德困扰的干预措施：对文献的系统回顾。教育干预提供了一个有希望的方向，但需要更多的研究。