Refinement and Testing of a Moral Distress Tool for Triservice Military Critical Care Nurses

The U.S. military services prides itself in delivering optimal care to its members often in unpredictable, unforeseeable, and austere conditions. In these types of healthcare environments, moral and ethical situations are likely to occur. When a provider recognizes an appropriate action to take but because of an internal or external constraint, is unable to act in a way that is consistent with their beliefs and moral integrity is compromised, moral distress occurs. This well-known phenomenon in civilian healthcare has been studied extensively since the 1980s and results in poor patient clinical outcomes, burnout, employment turnover, and increased healthcare expenses. A similar phenomenon well-studied in the military warfighter population is moral injury. Moral injury occurs when a warfighter has been betrayed in what’s right by someone who holds legitimate authority in a high stakes situation. Moral injury has been traditionally used in the context of a warfighter and moral distress has been applied to the healthcare provider but both have similar constructs and are poorly understood. Little research has been completed documenting moral distress and/or moral injury in military healthcare providers. But for a military critical care nurse practicing in various environments, they are simultaneously healthcare providers and warfighters, which may pose situations where both moral distress and moral injury are applicable. The outcomes may manifest with symptoms similar to PTSD, anxiety and
depression, and persistence over time will result in compromised care to our warfighters as well as a decreased ability to care for oneself.

The purpose of the proposed study is to refine and validate an instrument to assess moral distress in triservice military critical care nurses. The first aim of the study will attempt to harmonize and disseminate the conceptual understanding of moral distress and moral injury in the military critical care nurse. Current literature will be analyzed to compare and contrast moral distress and moral injury as it applies to the military critical care nurse. The second aim will refine the existing Moral Distress for Healthcare Professionals (MMD-HP) tool to measure moral distress in triservice military critical care nurses. The second aim will assess reliability and validity of this tool to measure moral distress in military critical care nurses. These efforts will bring together a group of diverse experts specializing in various aspects of moral distress, moral injury and military operational relevance in an instrument workshop to refine the existing civilian moral distress tool for healthcare providers who are engaged in direct patient care in acute care settings. This tool refinement will include military and critical care relevant concepts while integrating the understanding of moral injury in the warfighter into its constructs. Aim three will test the tool in critical care nurses from all military branches for validity and reliability. Testing will consist of content validity with subject matter experts followed by construct validity and reliability testing with critical care nurses from triservice military groups through a convenience sample questionnaire survey methodology. At the end of this study period, a valid and reliable tool to measure moral distress in military critical care nurses will be delivered to stakeholders with supporting psychometric properties. The tool will be used in future efforts to measure the impact of interventions to mitigate the negative effects of this detrimental outcome of providing care in this challenging environment.

This study supports the TriService Nursing Research Program priorities of Force Health Protection and Leadership, Ethics, and Mentoring. Specifically, it supports the subcategories of Fit and Ready Force and Care of the Caregiver. Additionally, efforts in this study will be the first to attempt to harmonize the military topic of moral injury with the healthcare topic of moral distress. The ability to test successful evidence-based interventions to lessen the detrimental effects of moral distress is dependent upon a reliable and valid tool to measure the phenomenon. The study proposed will deliver this tool.