PASTRY: A nursing-developed quality improvement initiative to combat moral distress

Abstract

Background:

High levels of moral distress in nursing professionals, of which oncology nurses are particularly prone, can negatively impact patient care, job satisfaction, and retention.

Aim:

“Positive Attitudes Striving to Rejuvenate You: PASTRY” was developed at a tertiary cancer center to reduce the burden of moral distress among oncology nurses.

Research Design:

A Quality Improvement (QI) initiative was conducted using a pre- and post-intervention design, to launch PASTRY and measure its impact on moral distress of the nursing unit, using Hamric’s Moral Distress Scale–Revised (MDS-R.) This program consisted of monthly 60-minute sessions allowing nurses to address morally distressing events and themes, such as clinicians giving “false hope” to patients or families. The PASTRY program sessions were led by certified clinicians utilizing strategies of discussion and mind-body practices.

Participants:

Clinical nurses working on an adult leukemia/lymphoma unit.

Ethical considerations:

This was a QI initiative, participation was voluntary, MDS-R responses were collected anonymously, and the institution’s Ethics Committee oversaw PASTRY’s implementation.

Findings:

While improvement in moral distress findings were not statistically significant, the qualitative and quantitative findings demonstrated consistent themes. The PASTRY program received strong support from nurses and institutional leaders, lowered the nursing unit’s moral distress, led to enhanced camaraderie, and improved nurses’ coping skills.

Discussion:

Measurement of moral distress is innately challenging due to its complexity. This study reinforces oncology nurses have measurable moral distress. Interventions should be implemented for a safe and healing environment to explore morally distressing clinical experiences. Poor communication among multidisciplinary team members is associated with moral distress among nurses. Programs like PASTRY may empower nurses to build support networks for change within themselves and institutions.

Conclusion:

This QI initiative shows further research on moral distress reduction should be conducted to verify findings for statistical significance and so that institutional programs, like PASTRY, can be created.

Introduction

Cancer is a leading cause of premature mortality (i.e., deaths at 30–69 years) in more than 100 countries and the second leading cause of death in many affluent countries, including the United States.¹ Oncology nurses are intermittently exposed to stressful clinical situations that may challenge their professional integrity. They may experience a range of negative emotions stemming from their innate duty to serve as moral agents, making moral distress an increasing concern.²

Various strategies have been employed to address ethical dilemmas, like promoting respite and building resilience among oncology nurses.² This article describes a nursing-developed intervention created at a tertiary care cancer center to decrease moral distress among oncology nurses, entitled “Positive Attitudes Striving to Rejuvenate You: PASTRY.”

Background

High levels of moral distress are well documented among nurses; oncology nurses are particularly susceptible because they regularly confront multiple stressors and experience complex life events right alongside patients for extended periods of time.^2–6 These include caring for patients with grave diagnoses and for families in emotional crisis, supporting patients through arduous cancer-directed treatment frequently with uncertain outcomes, witnessing an unnecessary prolonged dying period, and navigating through complicated patient caregiver relationships.^2,5,6 However, more research is needed on interventions to decrease the severity of moral distress, and how institutions can change their ethical climate to effectively foster moral resilience to support nurses and the nursing profession.^2–4,7,8

Moral distress was first described by Jameton in 1984 as the negative emotional response that occurs when a healthcare provider knows the morally correct action to take, but is prevented from doing so due to clinical situations or internal or external constraints.^9,10 This could be due to low healthcare hierarchal ranking, fear of physician backlash, or time constraints, to name a few.^2,3,9,11,12 Moral distress, compassion fatigue and burnout are often linked together as a conglomerate of issues, but they are each distinct problems with distinct effects. “Compassion fatigue” describes an extreme state of tension and preoccupation with the suffering of those being helped to a degree that is traumatizing for the helper.⁷ “Burnout” is a response to prolonged and/or chronic emotional and interpersonal stressors on the job and is defined by the dimensions of exhaustion, cynicism, and inefficacy.¹³ While all three concepts cause significant work-related stress, moral distress is the most complex and systemic, having three root causes of patient, unit and system.⁸ Moral distress may have a negative effect on the patient-nurse connection and communication, potentially leading to less attentive and effective care.¹² Additionally it is impacted by organizational factors, such as an evasive institutional culture, intensive clinical situations and fragmented inter-professional staff relationships.^2,8

Moral distress can potentially lead to an individual’s job dissatisfaction, physical symptoms including exhaustion, and psychological manifestations like anger, depression, or loss of trust.^3,14 It can pose a risk to nurses’ integrity, for instance when oncology nurses feel ethically distressed that the medical team has not been forthcoming with a patient’s terminal prognosis, or provides false hope, the nurse may limit his or her interactions with the patient in an effort to avoid sharing information inconsistent with the medical team’s messaging.⁶ This avoidance of patient care also affects multiple components of the healthcare system.^2,4,13,15,16

More broadly, moral distress can cause a pervasively over-taxed workforce within an institution, prompting oncology nurses to be more likely to leave their jobs, leading to high nursing turnover and a negative impact on patient care as nurse to patient ratios may change.^2,4,11,17 Thus, actions should be taken by institutions to decrease the level of moral distress, its impact on nursing, and cultivate the development of ethical competencies.^2,8

While there are various forms of such interventions, many focus on taking respite, such as partaking in the arts or a provided lunch, or resiliency training, and very few aim to decrease moral distress explicitly at our institution.^18,19 Evidence-based research shows positive results when group meetings are held where staff can cultivate a sense of understanding among colleagues and manage conflict.^2,17 This could be done by exploring morally distressing scenarios and skill development to better equip nurses with decision-making strategies and self-care practices.^15,17

To address moral distress in oncology nurses at a tertiary cancer center “Positive Attitudes Striving to Rejuvenate You: PASTRY” was developed by the first author on a pediatric oncology/stem cell transplant unit. The sessions were facilitated by clinicians, namely a Board-Certified Psychiatrist, Certified Meditation Instructors, a Board-Certified Chaplain, and a Registered Nurse (RN) who was also the hospital Ethics Committee Chair. PASTRY was piloted with once monthly sessions for 2 years during the day shift for the pediatric nursing staff. Pastries, tea, and coffee were provided, and the meetings had a flexible structure that allowed the nurses to select topics based on moral conundrums they were facing. The facilitators and attendees exchanged perspectives, discussed strategies to overcome work-related stressors, and practiced selfcare activities, such as mindful meditation or self-acupressure.

News of the PASTRY program’s existence spread to other oncology units within the institution through word of mouth. Initial feedback indicated that the nurses enjoyed the PASTRY sessions, but the extent to which a decrease in moral distress occurred was unknown. What began as a scheduled outlet for staff became the launch pad for a Quality Improvement (QI) study assessing an intervention for moral distress.

PASTRY uses the structural foundation of mind-body practice, as in mindful meditation, and discussion, including dialog and reflection of distressing occupational experiences, in a peer-to-peer group setting, to combat moral distress.^2,15,17

Research Question/Aim

The aim of this study is to determine if implementation of a formalized intervention, PASTRY, over 8 months lowered the level of moral distress in a cohort of nurses on the adult leukemia/lymphoma unit when compared to baseline.

Research Design

The study team initiated a Quality Improvement (QI) initiative utilizing an interventional pre- and postdesign, to assess the impact of the PASTRY program on the moral distress of a cohort of RNs caring for patients with liquid tumors at a tertiary care cancer center.

Instrument

Hamric’s Moral Distress Scale–Revised (MDS-R) measures respondents’ perceptions of a clinical experience based on the level of moral distress and frequency of which they meet the scenarios.¹¹ The MDS-R was chosen to assess the study outcomes because of its moderate construct validity (r = 0.22) and good reliability (Cronbach alpha = 0.89) among nurse respondents.^4,6,11 Six versions of the tool are available, based on targeted professions (nurses, physicians, and other healthcare providers) within either the adult or pediatric setting.¹⁸ The Nurse Questionnaire (Adult) version was used for this selected population of nurses caring for adult patients. The MDS-R tool describes 21 ethical/moral scenarios that are rated by the respondent for frequency of occurrence, using a Likert scale of 0–4 (never to very frequently) and level of disturbance perceived by that respondent (none to great extent), with lower numbers signifying lower levels of moral distress, and higher values signifying higher levels of moral distress.^4,20 Exact cut off ranges of low, moderate, or high moral distress have not been defined by Hamric et al. (2012).^4,16 The moral distress score of the MDSR validation sample was (91.53 (44.24)).

In addition, to the MDS-R, session notes and an open-ended survey item were collected to identify qualitative themes related to experiences participating in PASTRY. The free-text response item was integrated into the MDS-R follow-up survey and allowed participants to articulate experiences with PASTRY in their own words, serving as an important point of triangulation for the change in moral distress scores.

Participants

The clinical nurses of the adult leukemia/lymphoma unit at a tertiary cancer center were invited to participate as the intervention population, given they care for patients of high acuity with diagnoses restricted to hematologic malignancies.

Methods/Procedures

To study this intervention, a literature search was conducted on moral distress, its impact on nurses, available validated tools to measure moral distress, and recommended intervention design. The inpatient unit nurse leaders at the tertiary care cancer center were surveyed by email request to identify interventions and resources for moral distress currently in place for nursing staff. The survey responses indicated that the Positive Attitudes Striving to Rejuvenate You: PASTRY program was a unique intervention at the institution, as no other inpatient units were holding similar sessions focused on moral distress.

After securing Dr. Hamric’s permission, the Hamric’s Moral Distress Scale–Revised (MDS-R) was distributed using the Research Electronic Data Capture (REDCap) software at baseline and again after 8 months of PASTRY sessions. The baseline MDS-R was distributed using institutional email addresses with responses de-identified. Survey access was open for a 3 week period prior to the first PASTRY session. The follow-up survey was again distributed, requesting those who attended at least one session to complete the tool. Automatic reminders for completing the MDS-R tool were sent by email to the clinical nurses on the selected unit. The post-survey also included a free-text response item, where participants could write their reflections of the PASTRY intervention.

RNs on the unit promoted the PASTRY sessions by word of mouth, offered details about its objectives, and posted signs with the date, time, and location of the meetings, along with names and titles of the facilitators. RNs could attend one of the two 60-minute PASTRY sessions each month. Sessions were held back-to-back during the day shift for 8 months. Depending on their scheduled shifts they attended PASTRY between one and eight times. Seven to eight RNs attended each session, and no individuals in nursing administrative roles were included. Each PASTRY session was led by a Certified Meditation Instructor and a Certified Palliative Care Nurse Practitioner (NP). The 60 minute meetings were comprised of a 10- to 15 minute guided meditation and a 45- to 50 minute discussion. For consistency and to focus the sessions, one of the two facilitators read the same introduction at the beginning of each session to educate and remind the RN attendees of confidentiality and the purpose of the PASTRY program. The RNs attended voluntarily and created a partner coverage system, to allow the RNs in the PASTRY session to be free of patient responsibilities during that time.

In PASTRY sessions, the RNs in attendance raised, discussed, and reflected upon clinical scenarios that were distressing to them. Among themselves and with guidance from the trained facilitators they suggested coping strategies for challenging situations. The facilitators took de-identified notes immediately following the sessions, to allow them to remain engaged with the participants during PASTRY. These notes were later reviewed, along with free-text responses on the REDCap survey and coded to identify common themes regarding participant experiences in PASTRY, using a content analysis approach.²¹

All MDS-R survey data were exported from REDCap Software to Microsoft Excel and interpreted with the assistance of a biostatistician to assess pre- and post-intervention changes in scores. Moral distress was expressed as frequency from 0 (never) to 4 (very frequently) and level of disturbance (intensity) from 0 (none) to 4 (great extent).^4,20 The intensity was multiplied by frequency to create a composite score for multivariate analyses.⁴ The scores could range from 0 to 16, with lower scores representing lower levels of distress and higher scores representing higher levels.^4,11 The paired T-test (SPSS version 25 by IBM) was used in comparing baseline scores with post-intervention scores. The standard deviation was calculated, and a mean score of all respondents’ answers was determined to compute the nursing unit’s score for each of 21 questions. An overall distress level was expressed as sum of 21 composite scores of each individual question, with 0 being low distress and 336 being very high moral distress.^4,11,20 The same process was followed for both the pre- and post-surveys; then the nursing unit data sets were compared with the paired T-test parametric study. Scores were summarized and tested for significance.

Ethical Considerations

The Institutional Review Board (IRB) reviewed the PASTRY proposal on two separate submissions and deemed it a Quality Improvement (QI) initiative. They stated it did not align with Human Subjects Research, thus did not qualify for exempt or non-exempt research review and approval. MDS-R data were collected anonymously, and the investigators had no access to the email addresses of the PASTRY participants. Participation by the facilitators and the RNs was voluntary, RNs’ attendance was not taken at the meetings, and all notes taken for thematic analysis were de-identified. This QI initiative was also overseen by the institution’s ethics committee.

Findings/Results

The MDS-R baseline survey captured 23 nurses’ responses and 22 nurses completed the same survey after the PASTRY program intervention (96% response rate.) When comparing complete baseline scores of the nursing cohort with post-intervention scores using the paired T-test, the decreases in moral distress scores were not statistically significant (94 ± 49 vs. 84± 40, P = 0.18). Table 1 shows the mean composite score of moral distress experienced by the respondents, as a nursing unit, at baseline and post-intervention, as well as the percent difference between the two surveyed time points. They are organized by situations on the MDS-R with the largest decrease in moral distress score to largest increase in moral distress score. A decrease in the composite score for moral distress was demonstrated in 14 of the 21 (66.67%) ethical/moral scenarios from baseline to post-intervention.

Table 1:

Mean composite scores of the nursing unit’s moral distress at baseline and post-intervention, ranked by percent difference

	Baseline	Post-Intervention	p-value
Mean Moral Distress Scores (0 = never, 4 = very frequently)	94 ± 49	84 ± 40	0.18
Situation as stated by Hamric’s MDS-R	Baseline (out of max 16)	Post-Intervention (out of max 16)	Difference
21. Work with levels of nurse or other care provider staffing that I consider unsafe.	3.58	2.24	−37%
13. Follow the physician’s request not to discuss the patient’s prognosis with the patient or family.	4.89	3.32	−32%
19. Ignore situations in which patients have not been given adequate information to insure informed consent.	3.56	2.43	−32%
14. Increase the dose of sedatives/opiates for an unconscious patient that I believe could hasten the patient’s death.	2.11	1.64	−22%
8. Avoid taking action when I learn that a physician or nurse colleague has made a medical error and does not report it.	1.67	1.32	−21%
20. Watch patient care suffer because of a lack of provider continuity	6.70	5.33	−20%
4. Initiate extensive life-saving actions when I think they only prolong death.	9.93	7.95	−20%
9. Assist a physician who, in my opinion, is providing incompetent care.	5.15	4.33	−16%
18. Witness diminished patient care quality due to poor team communication.	8.15	6.91	−15%
3. Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient.	9.37	7.95	−15%
6. Carry out the physician’s orders for what I consider to be unnecessary tests and treatments.	9.23	7.86	−15%
7. Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support.	2.78	2.50	−10%
12. Provide care that does not relieve the patient’s suffering because the physician fears that increasing the dose of pain medication will cause death.	5.56	5.09	−8%
17. Work with nurses or other healthcare providers who are not as competent as the patient care requires.	3.07	2.86	−7%
16. Follow the family’s wishes for the patient’s care when I do not agree with them, but do so because of fears of a lawsuit.	3.22	3.27	2%
2. Witness healthcare providers giving “false hope” to a patient or family.	10.93	11.23	3%
10. Be required to care for patients I don’t feel qualified to care for.	1.56	1.64	5%
5. Follow the family’s request not to discuss death with a dying patient who asks about dying.	5.81	6.45	11%
11. Witness medical students perform painful procedures on patients solely to increase their skill.	1.04	1.91	84%
1. Provide less than optimal care due to pressures from administrators or insurers to reduce costs	0.93	2.23	141%
15. Take no action about an observed ethical issue because the involved staff member or someone in a position of authority requested that I do nothing.	1.00	3.05	205%

The five situations on the MDS-R deemed most morally distressing to the nurses based on composite score of frequency and level of disturbance are identified in Table 2. Two situations, both referencing authority “15. Take no action about an observed ethical issue because the involved staff member or someone in a position of authority requested that I do nothing” and “1. Provide less than optimal care due to pressures from administrators or insurers to reduce costs,” were major outliers in increase in moral distress composite scores. These two items scored the lowest overall mean composite scores on the baseline MDS-R (1.00 and 0.93, respectively), so any increase on the post-survey would reflect a large percent increase. This change could be due to a newfound awareness of ethical issues or a specific clinical event on the hospital unit at the time that was particularly distressing to the nursing staff, affecting responses on the MDS-R.³

Table 2:

Summary of Five Most Distressing Items (Ranked from highest mean composite moral distress score to lowest)

Situations ranked most distressing by this nursing unit cohort both pre- and post-intervention	Baseline (out of max 16)	Post-Intervention (out of max 16)
2. Witness healthcare providers giving “false hope” to a patient or family.	10.93	11.23
3. Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient.	9.37	7.95
4. Initiate extensive life-saving actions when I think they only prolong death.	9.93	7.95
6. Carry out the physician’s orders for what I consider to be unnecessary tests and treatments.	9.23	7.86
18. Witness diminished patient care quality due to poor team communication.	8.15	6.91

A qualitative analysis of participant quotes during the sessions and in free-text responses on the postintervention survey (11 of 22 answered the free-text item, 50% response rate) indicated a benefit of instituting the PASTRY program. Throughout the many sessions, the most frequently recurring themes the nurses discussed were 1) delivering end-of-life care to terminally ill cancer patients 2) the unrealistic expectations of some patients and families 3) caring for challenging and complex patient populations and 4) communication challenges with interdisciplinary staff. Written responses to the free-text section inquiring about the most morally distressing scenarios from personal clinical practice, included “poor communication with the MDs and RNs; some MDs tend to be dismissive” and “breakdown in communication among team members.”

The most morally distressing scenarios of this nursing cohort are reinforced through both the qualitative and quantitative data. Comparison of the qualitative and quantitative data show consistencies between qualitative theme and MDS-R items with a high distress score. For instance, two of the most distressing items (Table 2) on the MDS-R quantitative data were “Witness healthcare providers giving ‘false hope’ to a patient or family” and “Initiate extensive life-saving actions when I think they only prolong death.” Similarly, session notes and free-text reflections revealed that nurses experienced distress providing end of life care to terminally ill patients. One nurse candidly wrote he or she was particularly distressed with “Doctors not being appropriately up front with family and patient regarding prognosis.…It prolongs the agony of the patient family and the nurse involved.…It is morally distressing to be the only one to honestly talk to the patient or family if they ask your honest opinion and then it seems as though you are going against the medical team.”

In addition, the qualitative theme of “communication challenges with interdisciplinary staff” aligns with MDS-R item “Witness diminished patient care quality due to poor team communication,” which was ranked as a top distressing situation (Table 2.)

Another of the most distressing items from the MDS-R in this population was “Carry out the physician’s orders for what I consider to be unnecessary tests and treatments,” which correlate to the qualitative responses of “providing end of life care to terminally ill cancer patients,” as well as “communication challenges with interdisciplinary staff,” depending upon the real-life experiences to which the nurses are referring.

Similarly, nurses stated it was distressing when faced with “unrealistic expectations of some patients and families”, which could correlate to the second most distressing item on the MDS-R in this cohort, of “Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient.”

In post-session surveys, nurses also reported feeling a new sense of validation, camaraderie, and increased communication between senior and novice RNs because they had this dedicated time together to share experiences. One nurse expressed “it was really nice to know my co-workers feel the same way I do and to have the time to listen to their views.” Many stated that through PASTRY, they developed strategies for advocacy and approaching difficult situations by listening to other nurses and the facilitators’ guidance, and they felt more engaged to provide better patient care. “PASTRY has opened up communication between junior and senior staff. [The nurses] have witnessed consoling and empowering exchanges” that have fostered changes in the individual nurse, the unit, and the institution.

Several RNs noted PASTRY created a “healing and trusting environment,” allowing them to explore their own spirituality and religious beliefs in a “safe space.” Additionally, respondents reported that PASTRY facilitated new coping mechanisms, such as staff dinners, group discussions, humor, and exercise (including a unit running group.)

Several nurses reported in the survey that they felt a new “sense of belonging,” a realization that they were “not alone”, and a state of “feeling understood.” The consistent sessions created an “outlet” and a “healing and trusting environment.” Furthermore, PASTRY sessions were a “perfect place for our feelings to be known and cope” and the entire QI initiative was a “bonding experience [to] feel [we] are not alone” and a resource to communicate with “people who relate to what [we] deal with every day, [while] family and friends do not ‘get it’.” One nurse’s free-text response stated, “It [is] a great program that opens up conversations that may not be started if the program did not exist. [PASTRY] gives people the opportunity to hear others’ opinions or resolutions to situations they may have been facing.”

The design of PASTRY was intentionally made to be as convenient as possible for the nurses, so they could actually utilize the intervention. Nurses reported that reasons they could not attend a PASTRY session were demanding patient needs or staffing/scheduling conflicts preventing their attendance. Nursing responses did include they appreciated having the PASTY sessions held in a private room on the nursing unit, so they could attend without leaving the unit. Additionally, they valued not having to take personal time, out of work, to partake in the intervention.

Discussion

The findings of this study further emphasize the literature’s results that oncology nurses experience moral distress.^2,5,10,16 The level of moral distress experienced by this study’s oncology nursing cohort from each of the MDS-R scenarios ranged from 1 to 11.23 (out of 16.) A pre/post comparison of this QI initiative reveals an overall decrease in moral distress score, although the sample was not statistically significant.

Validated tools to measure moral distress exist; however, it remains theoretically and practically difficult to measure its severity and impact on nurses. This is due to its complexity and multiple contributing factors (i.e., patient, unit, system or complex clinical situations, interpersonal relations in staff, and organizational factors.) ^2,8,17

Furthermore, developing specific interventions to decrease moral distress proves to be challenging. Similar to this study, the Bruce and Allen study (2020) with a pre- and post-intervention design, also was unable demonstrate a statistically significant decrease in moral distress using the MDS-R. To decrease moral distress, efforts must be made by the individual nurse, the nursing team and the healthcare institution, and even then, it remains challenging.1 The qualitative responses from this study suggest the PASTRY program effectively alleviated moral distress across nurse, team and institution.

Unlike ethical conflict, moral distress often is a product of constraints in unit and healthcare system environments.³ Oncology nurses regularly confront existential issues as they care for complex patients, many of whom are at the end of life, which can be morally distressing if nurses are unable to practice as they intend due to other constraints.^{2,3,6,10,11,22} Identification of moral distress and development and implementation of interventions to address moral distress, such as PASTRY’s active discussion model, can lead to an improved workplace environment and ethical climate.^5,11,23 This is self-sustaining whereas, a unit with a well-developed and strong ethical climate should be less likely to foster situations of moral distress.^4,8

An implementation goal was to help the nursing staff by bringing an intervention to fit into a real-life oncology unit to increase accessibility to nurses. Through the PASTRY intervention design, the nurses felt comfortable being vulnerable to examine the numerous stressors they routinely face, as well as moral conundrums and their own mortality and spirituality. The open forum and congregating of nurses from novice to expert for discussion fostered reflection on past experiences, support on how to improve moral decision making, and advisement for the future.^13,24 The qualitative data revealed the nurses valued the healing and safe environment, for a healthier workplace environment and ethical climate.^{2–4,11,17,23,24}

Poor interdisciplinary communication was particularly distressing in this study sample by both qualitative and quantitative measures, and this is also consistent across other studies and literature of nurses’ moral distress.^2,12,25 Healthcare teams, notably in oncology, are comprised of multidisciplinary members. When inter-professional communication is fragmented, it can lead to misinterpretation and misunderstanding, which can subsequently cause moral distress among the team members.^2,25 To prevent their moral distress, nurses should be treated as equal partners of the multidisciplinary healthcare team and included in formal communication and deliberation.² Discussing examples of such interactions, exploring future tactics, and developing competencies in a group setting, like PASTRY, could help the nurses promote a multi-level change.^2,8,25

Limitations

The findings of this QI initiative were limited by several factors. In addition to the small sample size of the study, the investigators, facilitators, and participants had to reckon with the unpredictable nature of delivering clinical care to acutely ill patients and inconsistent attendance based on patients’ needs and staff schedules. Given this intended convenience design, future studies could include enrolling a specific cohort of participants to follow over time. The MDS-R scores were calculated into a mean score, reflecting the level of distress of the nursing unit. Some of the respondents who completed the MDS-R did not attend every PASTRY session, leading to variable frequency the participants may have experienced of the intervention.

Given the QI nature of this initiative and goal for anonymity, demographic information was not collectedon the clinical nurses who attended the PASTRY sessions. The facilitators took de-identified notes immediately after the PASTRY sessions, which were potentially limited by recall discrepancy or facilitator bias.

Recommendations

Future quantitative and qualitative studies can help to further examine moral distress and directed interventions in the nursing profession. These could encompass larger sample sizes and a non-intervention control group. While the Hamric MDS-R tool is a useful assessment for quantifying severity and frequency of moral distress, additional research is needed to develop a more comprehensive understanding.^4,11,17,26 In future studies, collecting demographic information to correlate the nurses pre- and post-intervention survey responses to assess moral distress scores and the intervention’s impact could benefit the study design. Additionally, holding these sessions during “administrative” or “non-clinical” work time as well as ensuring the nurses could attend every session would help to set up a more controlled study environment. The pre-intervention composite score (94 ± 49) was slightly higher than the moral distress score of the MDS-R validation sample (91.53 (44.24)), indicating that the participants in this study may exhibit a slightly elevated level of distress compared to other RN specialties.3 It could be studied if it is more challenging to make a significant decrease in the level of moral distress of this specific group of nurses given the higher baseline scores. It could also be studied if an increase in frequency in the PASTRY sessions, increase in number of PASTRY sessions attended, or an integration of physicians and other healthcare professionals would yield different results.

Conclusion

Moral distress is a significant problem that needs to be addressed among the nursing workforce.^2,3,11 It is in an institution’s best interest to endorse interventions to decrease moral distress because it can compromise nurses’ integrity and patient care, lead to job dissatisfaction and threaten nursing retention, increasing institutional costs.^6,11,13,15 Additionally due to the vastness of stressful, complex, and existential challenges that oncology nurses face, institutional support is needed to decrease moral distress.^2,6,11,18

The PASTRY program is an innovative, coordinated intervention aimed at decreasing moral distress. Staff and leadership welcomed the program and perceived a strong qualitative improvement in camaraderie and coping. PASTRY has built support networks among colleagues to empower change within themselves and the institution.

This QI initiative yields important insight into the benefit of the PASTRY program. These findings illustrate that moral distress should be explored in greater depth to quantify the problem and ways to improve it, including support for moral decision-making.⁴ The PASTRY program’s flexible structure allows discussions and strategies to be adapted to the needs of each individual unit to combat moral distress. Moral distress demands direct attention, consistent intervention, and program flexibility to evolve alongside additional research. With better understanding and increased support, additional purposeful interventions can be developed to reduce moral distress.