Development and pilot test of a conscientization intervention for nurses who have experienced moral distress
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Nurses act as moral agents for patients and use their moral sensitivity to build trusting relationships to act in patients’ best interests. However, nurses also lack power in their place of employment due to inequality in power relations. When this lack of power interferes with being a moral agent, moral distress occurs. Moral distress can lead to burnout and leaving the profession. In this dissertation, I sought to learn whether an intervention, guided by the principles of conscientization developed by the Brazilian philosopher and educational theorist Paulo Freire in his classic work, Pedagogy of the Oppressed, would be acceptable and feasible with nurses who had previously been exposed to moral distress. An interactive small-group intervention in three sessions was developed and piloted with 13 nurses within four different types of critical care units from three different hospitals. Pre-and post-intervention surveys were administered to measure change in psychological empowerment, structural empowerment and moral distress levels. Open-ended interviews were conducted at two weeks post-intervention to assess acceptability and feasibility, as well as the nurse’s sense of personal empowerment post-intervention. The pilot study demonstrated that the conscientization intervention is feasible and acceptable to participants. Narrative analysis of the moral distress stories revealed themes of powerlessness experienced by nurses in interactions with families, organizations, and physicians. Evaluation of goal attainment from each session revealed increased empowerment during the movement through the sessions of critical reflection, critical motivation, and critical action. Post intervention interviews indicated that nurses perceived that they gained an increased understanding of moral distress and a sense of personal and group empowerment after the intervention. Survey results showed a significant decrease in moral distress mean and frequency, a significant increase in moral distress intensity, and no significant change in mean levels of psychological or structural empowerment post intervention. The pilot study demonstrated that a conscientization intervention formulated around critical reflection, motivation, and action and delivered in a small-group format with nurses is a feasible and acceptable way to reduce moral distress levels and develop personal empowerment. Reducing moral distress among nurses is crucial for reducing burnout, improving retention, and improving patient care.
Table of Contents
Introduction -- Review of literature -- Methods -- Results -- Discussion -- Appendix A. Session One Tool “Understanding Ourselves -- Appendix B. Session One Tool “Understanding What Already” -- Appendix C. Session One Tool “Weighing Options” -- Appendix D. Schematic for Session One -- Appendix E. Session Two Tool “Understanding Where We Wish to Go” -- Appendix F. Schematic for Session Two -- Appendix G. Session Three Tool “Strategy Building” -- Appendix H. Session Three Tool “Action Project Template” -- Appendix I. Schematic Session Three- Appendix J. Demographic Tool -- Appendix K. MDS-R Tool -- Appendix L. MDS-R Tool Permission -- Appendix M. Psychological Empowerment Scale (PES) -- Appendix N. PES Permission -- Appendix O. Conditions at Work Effectiveness Questionnaire (CWEQ-II) -- Appendix P. CWEQ-II Permission -- Appendix Q. AACN Recruitment Letter -- Appendix R. AACN Permission -- Appendix S. Room Permission -- Appendix T. IRB Approval -- Appendix U. Post-Intervention Interview-Feasibility Questions -- Appendix V. Post-Intervention Interview-Empowerment Questions -- Appendix W. Coding of Moral Distress Story Nurse A -- Appendix X. Coding of Moral Distress Story Nurses K -- Appendix Y. Coding of Moral Distress Story Nurse F -- Appendix Z. Coding of Moral Distress Story Nurse B -- Appendix AA. Coding of Moral Distress Story Nurse C -- Appendix BB. Coding of Moral Distress Story Nurse D -- Appendix CC. Coding of Moral Distress Story Nurse E -- Appendix DD. Coding of Moral Distress Story Nurse G -- Appendix EE. Coding of Moral Distress Story Nurse H -- Appendix FF. Coding of Moral Distress Story Nurse I -- Appendix GG. Coding of Moral Distress Story Nurse J -- Appendix HH. Coding of Moral Distress Story Nurse L --Appendix II. Coding of Moral Distress Story Nurse M -- Appendix JJ. Structural Code Analysis Coding of Moral Distress Stories -- Appendix KK. Group 2 Intervention Data -- Appendix LL. Group 3 Intervention Data
Ph.D. (Doctor of Philosophy)