目标:在他们职业生涯的某个阶段,许多医护人员会经历与无法采取道德或道德上正确的行动有关的心理困扰,因为它符合他们自己的价值观;一种被称为道德困扰的现象。同样,有越来越多的报告说,医护人员经历了长期的精神和心理痛苦,除了内部不和谐,被称为道德伤害。这篇综述研究了在一系列临床环境中使用的健康和社会护理人员(HSCW)中与道德困扰和伤害相关的触发因素和因素,目的是了解如何减轻道德困扰的影响并确定潜在的预防性干预措施。
方法:根据Cochrane和系统评价和荟萃分析指南的首选报告项目的建议进行系统评价和报告。在2024年1月之前,对2个主要数据库进行了定期搜索和更新(CENTRAL,PubMed)和三个专业数据库(Scopus,CINAHL,PsycArticles),同时手工搜索研究登记数据库和其他系统评价参考列表。符合条件的研究包括HSCW样本,探索道德困扰/伤害作为主要目标,用英语或意大利语写的.逐字引用被提取,文章质量通过CASP工具包进行评估。进行了主题分析,以确定模式并将代码安排到主题中。探讨了文化和多样性等具体因素,以及大流行等特殊情况的影响。
结果:49项研究的51份报告被纳入综述。原因和触发因素分为三个领域:个人,社会,和组织。在个人层面,患者的护理选择,专业人士的信仰,控制源,任务规划,以及根据经验做出决定的能力,被指示为可能导致或引发道德困扰的元素。此外,与CoVID-19大流行有关,使用/访问个人保护资源。社会或关系因素与倡导和与患者及家属沟通的责任有关,和专业人员自己的支持网络。在组织层面,层次结构,法规,支持,工作量,文化,和资源(人员和设备)被确定为可能影响专业人员道德舒适度的要素。病人护理,道德/信仰/标准,宣传作用和背景文化是最有参考意义的要素。关于文化差异和多样性的数据不足以做出假设。缺乏资源和迅速的政策变化已成为与大流行有关的关键触发因素。这表明,那些负责政策决定的人应该注意突然和自上而下的变化对工作人员的潜在影响。
结论:这篇综述表明,道德伤害的原因和触发因素是多因素的,并且在很大程度上受专业人员工作的背景和制约因素的影响。道德困扰与照顾的义务和责任有关,和专业人员优先考虑患者的健康。如果组织的价值观和规章制度与个人的信仰相反,对专业人士的健康和保留的影响是可以预期的。减轻道德困扰的组织策略,或长期的道德伤害后遗症,应该针对个人,社会,以及本次审查中确定的组织要素。
OBJECTIVE: At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This
review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions.
METHODS: A systematic
review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic.
RESULTS: Fifty-one reports of 49 studies were included in the
review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients\' care options, professionals\' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals\' moral comfort. Patients\' care,
morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change.
CONCLUSIONS: This
review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals\' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals\' beliefs, repercussions on professionals\' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.