AN INDEPENDENT VOICE FOR NURSING

Work Engagement, Moral Distress, Education Level, and Critical Reflective Practice in Intensive Care Nurses nuf_237 256..268

Lisa A. Lawrence, PhD, RN Lisa A. Lawrence, PhD, RN, Instructional Faculty, Nursing Department, Pima Community College, Tucson, AZ Keywords Critical reflective practice, education level, moral distress, registered nurse, work engagement Correspondence Lisa A. Lawrence, PhD, RN, Nursing Department, Pima Community College, Tucson, AZ E-mail: llawrence@pima.edu
AIM. The purpose of this study was to examine how nurses’ moral

distress, education level, and critical reflective practice (CRP) related to their work engagement. The study is relevant to nursing, given registered nurse (RN) documented experiences of job-related distress and work dissatisfaction, and the nursing shortage crisis. A better understanding of factors that may enhance RN work engagement is needed. METHODS. A non-experimental, descriptive, correlational design was used to examine the relationships among four variables: moral distress, education level, CRP, and work engagement. The sample included 28 intensive care unit RNs from three separate ICUs in a 355-bed Southwest magnet-designated hospital. RESULTS. There was a positive direct relationship between CRP and work engagement, a negative direct relationship between moral distress and work engagement, and CRP and moral distress, together, explained 47% of the variance in work engagement. Additionally, in the neonatal intensive care unit, a positive direct relationship between increased educational level and CRP was identified, with a suggested negative relationship between increased education level and moral distress. IMPLICATIONS. Strategies to promote CRP and reduce moral distress are recommended, to promote RN work engagement. Additionally, further study on the role of education in nurses’ work engagement is recommended.

Registered nurses (RNs) are important to a nation’s well-being, for nearly every healthcare experience, from birth to death, involves the contribution of an RN (Joint Commission on Accreditation of Healthcare Organizations, 2002, p. 5). The current and increasing RN shortage in the United States represents a serious threat to quality health care. RNs currently in practice experience greater demands in constrained environments, i.e., increased patient acuity, technology changes, nursing shortages, shorter lengths of stay, and financial pressures (Kurtzman & Corrigan, 2007, p. 26). As the profession’s goal of providing care that promotes healing and prevents complications is challenged, RNs are at risk to experience job-related distress and
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dissatisfaction, with resultant potential exit from the profession (Lang, 2008). Clinical research has studied patients and illnesses, but it is now time, especially given the growing shortage of RNs, to include the professional well-being of RNs in scholarly work. For in view of the “increasing shortfall of competent workers . . . it is crucial to retain and motivate . . . personnel . . . [and] to examine the conditions and processes that contribute to the optimal functioning and happiness of [nurses]” (de Lange, De Witte, & Notelaers, 2008, p. 201). The aim of this study is to examine and expand the nursing knowledge base in regards to nurses’ work engagement and factors that may enhance this work experience for nurses. A

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Nurse’s Education Level Nurse’s education level is a representation of the educational avenue utilized to obtain a current RN licensure-to-practice degree and is usually represented in one of three ways: (a) 2-year associate degree in nursing (A.D. or A.D.N.), (b) 3-year diploma degree, or (c) 4-year baccalaureate of science degree in nursing (B.S.N.). Since 2003, after it was identified the care provided by four-year and higher degree educationally prepared RNs was potentially related to lower mortality and failure-to-rescue rates in hospitalized patients, there became an increased interest in “whether and how educational levels of nurses are causally related to patient outcomes” (Clarke & Connolly, 2004, p. 16). Although advancing the existing knowledge base regarding RNs’ educational preparation and its relationship to quality of care (Kurtzman & Corrigan, 2007, p. 27) is important, the intent of this study is to extend the knowledge base in regards to how RNs’ educational preparation may relate to work engagement. Currently, no published research directly examines how RNs’ educational preparation relates to work engagement. A Belgian, all-sector workforce study on work engagement identified, however, that a more highly educated workforce, along with job autonomy and work environment resources (e.g., adequate staffing), predicted an intention to stay within a position (De Lange et al., 2008). Although substantial evidence is lacking, it appears higher education may relate positively to work engagement. Moral Distress Moral distress is “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision” (Wilkinson, 1987/1988, p. 16). In this study, moral distress is proposed as one potential factor in the complex and worldwide trend of decreased RN recruitment, retention, and work satisfaction. It is experienced by RNs in the following variety of care provision settings: medical-surgical/acute-care (Corley, Minick, Elswick, & Jacobs, 2005; Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008; Storch, Rodney, Pauly, Brown, & Starzomski, 2002; Verhaeghe, Vlerick, De Backer, Van Maele & Gemmel, 2008; Wilkinson, 1987/ 1988; Zuzelo, 2007), home care (Liaschenko, 1995), occupational health (Corley, Elswick, Gorman, & Clor,
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secondary aim of this study is to present a proposed theoretical framework of significant correlates of work engagement, it is understood that the theoretical framework may be refined as a result of the study.

Background and Significance The United States is experiencing a disturbing nursing shortage (Buerhaus, 2009; Buerhaus, Auerbach, & Staiger, 2009). There are indications “by 2011 the number of nurses leaving the profession will exceed the number of new nurses entering the profession” (Hart, 2005, p. 174) and by 2020 hospitals will face “a 20% nursing shortage” (Bell & Breslin, 2008, p. 95). Additionally, a majority of United States workforce nurses (51.8%) report moderate satisfaction with their primary job, and 29.8% report they have left a position or intend to leave a position within the year (United States Department of Health and Human Resources & Health Resources and Services Administration, 2010). An approach to gaining better understanding of nurses’ work experiences and possible explanation for dissatisfaction with work is through study of factors that may influence nurses’ work engagement. Work engagement is important because recent and in press findings suggest engaged employees experience (a) happiness, joy, and enthusiasm; (b) better physical and psychological health; (c) improved job performance; (d) increased ability to create job and personal resources, e.g., support from others; and (e) an ability to transfer their work engagement to others (Bakker, Schaufeli, Leiter, & Taris, 2008, pp. 193–194). The purpose of this study is to examine how nurses’ education level, moral distress, and critical reflective practice (CRP) relate to their work engagement.

Literature Review and Theoretical Framework The personal and environmental factors of nurses’ education level, moral distress, and CRP are proposed to be significant correlates of work engagement among nurses. CRP, a term coined by the investigator, is a new concept developed for this study and CRP is proposed to be a positive, significant correlate to work engagement. The clinical, conceptual, and empirical literature for nurse’s education level, moral distress, CRP, and work engagement was reviewed and a summary of findings follows.

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Critical Reflective Practice in Intensive Care Nurses
2001), military (Fry, Harvey, Hurley, & Foley, 2002), cardiology and hematology (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004), psychiatry (Forchuk, 1991; Liaschenko, 1995), peri-operative (Von Post, 1998), palliative care (Georges & Grypdonck, 2002), dialysis, skilled/long-term care, maternity, acute rehabilitation, and telemetry (Zuzelo, 2007), and critical care/neonatal intensive care (Corley et al., 2001; Cronqvist, Theorell, Burns, & Lützén, 2004; Gutierrez, 2005; Hamric & Blackhall, 2007; Hefferman & Heilig, 1999; Meltzer & Huckabay, 2004; Mobley, Rady, Verheijde, Patel, & Larson, 2007; Sundin-Huard & Fahy, 1999; Verhaeghe et al., 2008; Zuzelo, 2007). Moral distress, a term coined in 1984, arises when institutional constraints make it nearly impossible for nurses to pursue a course of action they believe is right (Jameton, 1984, p. 6). For example, nurses believe it is important to protect patients from harm (Corley, 2002, p. 637) yet, in neonatal intensive care units (NICUs) where advanced technology capabilities and extremely premature infants born at 23–24 weeks co-exist, there is an expectation of a “no holds barred” (Hefferman & Heilig, 1999, p. 174) approach to resuscitation and pharmacological treatment. In this environment RNs begin to wonder whether it is appropriate to pursue such aggressive treatment when chances for intact survival are dismal. Carried out by their own hands, perceptions of futile care contribute greatly to the development of moral distress. Some scholars suggest the healthcare environment may constrain and/or violate the values of professional nurses. Registered nurses operate in hierarchical systems where they interpret that the hospital leaders, i.e., physicians and nurse supervisors, ignore their needs (Eizenberg, Desivilya, & Hirschfeld, 2009, p. 890; Storch et al., 2002; Sundin-Huard & Fahy, 1999; Zuzelo, 2007, pp. 354–356). Registered nurses perceive significantly less collaboration in the work environment than medical doctors (Hamric & Blackhall, 2007) and commonly struggle with, and fear, retribution from hospital leaders if they act as patient advocates (Gutierrez, 2005). Moral distress is experienced because the nurses’ integrity to protect a patient from harm is compromised, and feelings of remorse, shame and/or guilt ensue (Rushton, 1995, p. 369). Because moral distress is associated with “traditional negative stress symptoms, such as feelings of frustration, anger and anxiety, which might lead to depressions, nightmares, headaches and feelings of
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worthlessness” (Kälvemark et al., 2004, p. 1077), RNs who experience moral distress are likely to be dissatisfied with their work, leave a position, exit the profession, or avoid patients (Corley et al., 2001, 2005; Georges & Grypdonck, 2002; Gutierrez, 2005; Hamric & Blackhall, 2007; Millette, 1994; Wilkinson, 1987/1988). Currently, no published research has been found in which the relationship between moral distress and work engagement was studied. However, the dynamics of moral distress support the idea that it may negatively relate to work engagement. CRP CRP, a concept developed for this study by the investigator, is another element that may be a significant factor in nurses’ work experiences and work engagement. CRP is defined as being mindful of self within or after professional practice situations, i.e., processing the cognitive, behavioral, moral (ethical), socio-political, and affective components of professional practice situations, so as to continually grow, learn, and develop, personally, professionally, and politically. A synthesis of reflection, reflective practice, and critical reflection literature led to the development of this new concept named CRP. CRP is “critical” because it encourages RNs to develop an awareness of their personal beliefs, some of which may be “unconsciously held beliefs” (Tate, 2004, p. 9), and encourages RNs to examine why certain practice choices are made. It also encourages RNs to examine how domination by authoritarians influences their decisions, i.e., there is concern with an examination of the “ethical and moral issues related to justice and equality” (Teekman, 2000, p. 1127). Through the process of CRP, RNs confront, understand, and move toward resolving contradiction between personal vision and actual practice, they realize desirable practice (Johns, 2006, pp. 2–3). Both internal and external RN experiences are included in CRP and focus is upon an ontological practice perspective, i.e., upon a RN’s “being” in practice (Rolfe & Gardner, 2006, p. 595). Salient factors within critical reflection include the affective, moral (or ethical), behavioral, cognitive, and political dimensions of practice. According to Christopher Johns (2006), nurse scholar and Buddhist, critical reflection includes the affective component of “feelings” (Johns, 2006, pp. 30–31) and it is the development of feelings that culminates in “voice” (Johns, 2006, p. 10), or personal

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Critical Reflective Practice in Intensive Care Nurses dedication, and absorption” (Schaufeli, Salanova, González-Romá, & Bakker, 2002, p. 74). “Certainly something worth promoting” (Taris, Cox, & Tisserand, 2008, p. 185), work engagement is characterized by high levels of energy at work, mental resilience while working, a willingness to invest effort in one’s work, persistence even in times of difficulty, a sense of enthusiasm, inspiration, pride, and challenge in regards to one’s work, and being deeply engrossed and fully concentrated in one’s work (Schaufeli et al., 2002). Work engagement represents a “motivational process that is driven by the availability of resources” (Schaufeli & Bakker, 2004, p. 310). Both job resources, i.e., supervisory coaching, financial rewards, performance feedback, autonomy, career opportunities, etc., and personal resources, i.e., optimism, self-efficacy, selfesteem, etc., may engage employees, who then “work hard (vigour), are involved (dedicated), and feel happily engrossed (absorbed) in their work” (Bakker et al., 2008, p. 190). In this study, three nursing factors not yet studied will be examined for their relationship to work engagement: the personal factors of education level and moral distress, and the personal work-environmental factor of CRP. These factors, i.e., nurse’s education level, moral distress, and CRP, have been implicated in the literature as relevant to nurses’ work experiences and satisfaction. Theoretical Model Based upon a review of the literature the investigator developed a theoretical model, see Figure 1. The theoretical model proposes the following relationships: 1. A negative relationship between moral distress and work engagement, which may be positively modified by CRP 2. A posited negative relationship between CRP and moral distress; 3. A posited positive relationship between increased RN education level and CRP, and work engagement; and 4. A posited negative relationship between increased RN education level and moral distress. Research Questions

vision for practice, which empowers RNs to take caring action based upon insight. From the perspective of Johns (2006), RNs: (a) experience a “creative tension” (Johns, 2006, p. 7) between personal visions of nursing practice and current reality; and (b) are exposed to limited support availability (Johns, 2006, p. 201), i.e., inadequate staffing, limited meeting space and meeting time, transactional leadership, limited study time allocation, etc., which socializes them to be an oppressed group (Johns, 2006, p. 65). To enhance and develop critical reflection, practitioners are asked to share feelings about experiences and this process helps RNs develop a vision for practice, it provides the impetus for practitioners to take action, perhaps socio-political action (Heath, 1998), in order to resolve contradictions between their caring vision and “work as a lived reality” (Johns, 2006, p. 79). Some scholars reference this as double-loop learning (developing practice) versus single-loop learning (an academic exercise) (Duke & Appleton, 2000). With double-loop learning the agent does not merely search for alternative actions to achieve some ends, she also examines the appropriateness and propriety of her chosen ends (Greenwood, 1998, p. 1049). Although reflection definitions are ambiguous, many nurses believe, theoretically, that because reflection promotes greater self-awareness and an integration of theoretical concepts to practice, reflection enhances self-esteem, empowers nurses, and improves practice (Gustafsson, Asp, & Fagerberg, 2007; Ruth-Sahd, 2003). The notion of “reflective practice,” for example, is so popular in the United Kingdom that the government now requires post registration nurses, e.g., RNs practicing in work environments, to include “reflective practice” as part of their ongoing education (Gustafsson et al., 2007, p. 156). At the same time, nurses acknowledge additional outcomes research is necessary to validate these beliefs (Gustafsson et al., 2007; PedenMcAlpine, Tomlinson, Forneris, Genck, & Meiers, 2005). Much of the current literature related to reflection is either theoretical or qualitative-research based. This quantitative study examines CRP and its relationship to work engagement, the theoretical idea that CRP may be positively related to work engagement is supported. Work Engagement Work engagement is “the positive, fulfilling, workrelated state of mind that is characterized by vigor,

The following research questions were proposed in this study (Questions 1 through 4 are quantitative and Question 5 is qualitative):
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Figure 1. Theoretical Model: Proposed Relationships Among Registered Nurse Education Level, Moral Distress, Critical Reflective Practice, and Work Engagement

1. What are the levels of each variable (work engagement, moral distress, education, reflection and CRP) among RNs working in a southwestern magnetdesignated hospital? 2. What are the bivariate correlations among all of the variables? a. What are the relationships among moral distress, education level, reflection, CRP, and work engagement? b. How does RN education level relate to moral distress, reflection, CRP, and work engagement? c. How does moral distress relate to reflection, CRP, and work engagement? 3. What variables taken together (education level, moral distress, reflection, and CRP) best explain the variance in work engagement? 4. What role does CRP or reflection play in the relationship between moral distress and work engagement? a. Does CRP moderate the relationship between moral distress and work engagement? b. Does CRP or reflection have a direct relationship to moral distress? c. Does CRP or reflection have a direct relationship with work engagement? 5. Do RNs identify themes in their educationallearning experiences, work-related experiences, moral issue experiences, and reflective practice experiences? (to address Question 5, one openended question, see items a–e in the following,
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was placed at the end of each of the study’s five questionnaires). a. What learning experience, in your most recently completed nursing educational program, has best prepared you for nursing practice? (educationallearning experiences, placed at end of demographic data collection tool) b. What factors in your work setting, if any, may be worthwhile to examine? (work-related experiences, placed at end of work engagement scale) c. Please add any comments you may have about your experiences with moral issues in your practice. (moral issue experiences, placed at end of moral distress subscale) d. How do you reflect upon your practice experiences? (reflective practice experiences, placed at end of CRP scale) e. Is there anything else that you would like to add after responding to all of these questions? (reflective practice experiences, placed at end of reflection subscale)

Methods A non-experimental, descriptive, correlational, mixed methods study was designed to examine how RNs’ education level, moral distress, and CRP relate to their work engagement.

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Sample

Critical Reflective Practice in Intensive Care Nurses missing data cases the extent of the problem was not large and a participant-mean substitution occurred. A sample size of 28 participants was deemed acceptable as statistically significant findings resulted at this sample size level. The majority of participants were Caucasian/white (85%, 24/28), females (96%, 26/27) educated at the baccalaureate level (57%, 16/28) who worked fulltime (86%, 24/28). Participants worked a mean number of 8.6 years in an ICU setting (range 1 to 29, standard deviation [SD] = 7.8) and their mean number of years since first becoming a RN was 11.4 (range 1 to 42, SD = 1.4). Nine participants (32%, 9/28) had previously taken a leave from their work, e.g., an extended period of time away from the work environment. The largest proportion of extended work leave was demonstrated by PICU (45%, 5/11) and NICU (43%, 3/7), compared with MICU (1%, 1/10). Table 1 presents a summary of reported demographic characteristics, e.g., work status, gender, race/ethnicity, extended work leave, age, and RN years, by intensive care unit. Table 2 presents a summary of reported demographic characteristics, e.g., highest degree earned and seeking a higher degree, by intensive care unit.

The study was approved by the IRB Human Subjects committee. A convenience sample of 198 intensive care unit RNs (46 = medical intensive care unit [MICU], 62 = pediatric intensive care unit [PICU] and 90 = NICU) from a 355-bed, southwestern magnetdesignated hospital were identified for recruitment for study participation. The inclusion criteria for study participation were: (a) RN status; (b) greater than or equal to 50% of on-duty work time spent in the provision of direct nursing care to patients in an ICU setting; (c) greater than or equal to 20 hr of work time per week; and (d) computer literacy. A power analysis revealed an appropriate sample size for this study would be 33 participants, to attain a large effect size of .80, an alpha level of .05, and a beta of .20. Thirty-two RN-participants initially responded to the on-line study questionnaire, with 28 meeting criteria (N = 28) for data analysis. The overall study response rate was 14% (28/198). Respective ICU response rates were: (a) MICU 22% (10/46); (b) PICU 18% (11/62); and (c) NICU 8% (7/90). Five of the eligible 28 participants (18%) demonstrated missing data in their question responses. In each of the five

Table 1. Reported Demographic Characteristics (Work Status, Gender, Race/Ethnicity, Extended Work Leave, Age, and RN Years), by Intensive Care Unit (Medical Intensive Care Unit [MICU] = 10; Neonatal Intensive Care Unit [NICU] = 7; Pediatric Intensive Care Unit [PICU] = 11; Total N = 28)
MICU Range Mean (SD) n (%) Work status Full-time >20 hr per week Gender Female Male Race/Ethnicity Caucasian/White Hispanic/Latino Asian/Pacific islander Other Extended work leave Age (in years) 22–53 RN years Worked in ICU 1–13 Since first became RN 1–27 10 (100) 0 (0) 9 (90) 0 (0) 7 0 1 1 1 8 (70) (0) (10) (10) (10) (80) NICU Range Mean (SD) n (%) 5 (71) 2 (29) 7 (100) 0 (0) 7 0 0 0 3 7 (100) (0) (0) (0) (43) (100) 23–60 1–20 1–35 PICU Range Mean (SD) n (%) 9 (82) 2 (18) 10 (91) 1 (9) 9 2 0 0 5 10 (82) (18) (0) (0) (45) (91)

36.4 (10.2) 5 (3.8) 6.6 (8.0)

25–62

52 (14.9)

37.1 (11.6) 9.7 (6.6) 12.1 (10)

9 (90) 9 (90)

2.5–29 12.2 (12.4) 2.8–42 17.6 (16.3)

6 (86) 6 (86)

11 (100) 11 (100)

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Table 2. Reported Educational Demographic Characteristics (Highest Degree Earned and Seeking Higher Degree), by Intensive Care Unit (Medical Intensive Care Unit [MICU] = 10; Neonatal Intensive Care Unit [NICU] = 7; Pediatric Intensive Care Unit [PICU] = 11; Total N = 28)
MICU Range Highest degree earned Diploma Associate Bachelor’s Seeking higher degree Bachelor’s of science Master’s of science Mean (SD) n (%) 1 (10) 1 (10) 8 (80) 0 (0) 2 (20) NICU Range Mean (SD) n (%) 1 (14) 4 (57) 2 (29) 1 (14) 0 (0) PICU Range Mean (SD) n (%) 0 (0) 5 (45) 6 (55) 2 (18) 1 (9)

Data Collection Procedure An on-line survey format, e.g., SurveyMonkey, was used to collect data. SurveyMonkey employs multiple layers of protection to ensure that accounts and electronic data remain private. All data were de-identified by SurveyMonkey before being sent to the researcher. Several strategies were used to encourage study participation. Recruitment strategies included: (a) nurse managers, who were familiar to the respondents, sent the recruitment message, (b) participants were invited to enter a raffle for a random drawing for three $50.00 gift certificates to a Target department store, and (c) a 2-week email reminder, post study initiation, was forwarded to prospective participants by the respective nurse managers. It was anticipated these strategies would be sufficient to encourage study participation, because of the research emphasis inherent within magnet-hospital designation. Instruments Five data collection instruments were used in the study: (a) Demographic Data Collection Tool (14 items); (b) Utrecht Work Engagement Scale (UWES); (17 items); (c) Moral Distress Scale (MDS), in part; (the not in the patient’s best interest subscale); (7 items); (d) Critical Reflective Practice Questionnaire (CRPQ, a tool developed by the investigator of this study) (22 items), and (e) Reflection-Rumination Questionnaire (RRQ), in part (the reflection subscale) (12 items). One open-ended question was posed at the end of each data collection instrument (see Research Question 5,
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a–e). The use of questionnaires was proposed to elicit participants’ perspectives, whereas one open-ended question at the end of each instrument was proposed to allow the “language and words of participants” (Creswell, 1998, p. 186) to be included in the findings. The UWES (0–6 Likert), MDS subscale (0–6 Likert), and RRQ subscale (1–5 Likert) all demonstrate a Cronbach’s a greater than or equal to .83. Respective populations associated with the Cronbach’s a-values include: (a) an all-sector workforce (UWES); (b) registered nurses (MDS subscale); and (c) undergraduate psychology students (RRQ subscale). The CRPQ (1–7 Likert) was constructed by the investigator of this study, in collaboration with her Dissertation Chair, and was pilot tested in this research project. Higher scores on all study instruments reflect higher levels of work engagement, moral distress, reflective disposition, and CRP. Because the CRPQ is a new tool a standardized reflection measurement tool, e.g., the reflection subscale of the RRQ, was included in the study. It was thought that if the CRPQ was found to be inadequate, the study questions could be addressed using the RRQ reflection subscale. In addition, it was thought that inclusion of the RRQ reflection subscale may allow for analysis of construct validity, by examining correlations between the RRQ and CRPQ. Findings Research Question 1 Research Question 1 was answered using descriptive statistics. Table 3 presents the levels of work

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Table 3. Levels of Work Engagement, Moral Distress, Reflection, and Critical Reflective Practice for each Subgroup (Medical Intensive Care Unit [MICU] = 10; Neonatal Intensive Care Unit [NICU] = 7; Pediatric Intensive Care Unit [PICU] = 11; Total N = 28)
Possible range Work engagement MICU NICU PICU Moral distress MICU NICU PICU Reflection MICU NICU PICU Critical reflective practice MICU NICU PICU 0–6 0–6 0–6 0–6 0–6 0–6 0–6 0–6 1–5 1–5 1–5 1–5 1–7 1–7 1–7 1–7 Actual range 2.1–5.7 2.1–5.2 2.4–5.6 3.6–5.3 0.57–5.7 3.7–5.7 0.57–4.2 1.4–3.4 1.8–4.9 2.9–4.8 1.8–4.3 2.4–4.9 3.6–6.1 3.7–6.1 3.6–5.2 4.0–5.5 Mean (SD) 4.0 3.6 3.9 4.4 3.2 4.5 2.3 2.5 3.4 3.7 3.4 3.2 4.5 4.6 4.4 4.5 (0.88) (1.01) (1.06) (0.44) (1.3) (0.63) (1.14) (0.81) (1.31) (0.63) (1.14) (0.81) (0.61) (0.78) (0.90) (0.51)

engagement, moral distress, reflection, and CRP. Table 2, cited earlier, presents education levels. The MICU demonstrated a significantly higher MDS mean score (4.5, SD 0.63), compared with NICU (2.3, SD 1.14) and PICU (2.5, SD 0.81). An analysis of variance (ANOVA) confirmed MICU’s MDS subscale mean score (not in the patient’s best interest) was significantly higher than NICU and PICU (F = 19.29 [2, 25], p = .000). An ANOVA with all other variables, i.e., work engagement, moral distress, reflection, and CRP, demonstrated no statistically significant mean score differences. The U.S. RNs in this study demonstrated lower work engagement scores (4.0, SD 0.88) than their Finnish counterparts (4.20 to 4.36) (Mauno, Kinnunen, & Ruokolainen, 2007). Because this is the first study to examine CRP RN scores (4.5, SD 0.61), no comparison CRP scores are available. In terms of the RRQ reflection subscale, the RNs in this study demonstrated a higher RRQ reflection score (3.4, SD 1.31) than British Columbia undergraduate students in an introductory psychology class (3.14) (Trapnell & Campbell, 1999, p. 294). Research Question 2 Research Question 2 was answered using Pearson’s r correlation. In this study, two significant correlations

Table 4. Intercorrelations Between Moral Distress, Education Level, Reflection, Critical Reflective Practice, and Work Engagement (N = 28)
Subscale 1. 2. 3. 4. Moral distress Education level Reflection Critical reflective practice 5. Work engagement 1 — 2 -.03 — 3 .21 -.11 — 4 -.16 .13 .16 — 5 -.48* -.03 -.10 .56** —

**p = 0.01, *p = 0.05.

were demonstrated in the total sample: (a) CRP and work engagement were significantly and positively related (r = .56, p = .01, r2 = .31); and (b) moral distress and work engagement were significantly and negatively related (r = -.48, p = .05, r2 = .23). No other significant correlations were found. Table 4 presents the inter-correlations between moral distress, education level, reflection, CRP, and work engagement. Of note, inconsistent with the total group analysis, education level and CRP were significantly and positively related (r = .78, p = .05) in the NICU only, whereas the education level and moral distress were negatively
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Critical Reflective Practice in Intensive Care Nurses related at a suggestive, yet non-significant, level in the NICU (r = -.61, p = not significant [NS]). The construct validity of the CRPQ was examined in reference to its correlation with the RRQ reflection subscale (r = .16, p = NS, N = 28). The CRPQ correlated with the RRQ at a non-significant coefficient of .16. However, it was identified the RRQ reflection subscale may not be as congruent with the CRPQ, as anticipated. According to Brown and Ryan (2003), the RRQ reflection subscale measures a cognitive aspect, the “cognitive operations on aspects of self through selfexamination” (Brown & Ryan, 2003, p. 823). In contrast, CRPQ measures affective, moral (or ethical), behavioral, cognitive, and political dimensions of practice. Research Question 3 Research Question 3 was answered using stepwise multiple regression. In this study, the variables CRP and moral distress, taken together, explained the most variance in work engagement (R2 = .47, p = .00). Research Question 4 Research Question 4a was answered using stepwise hierarchical multiple regression. The findings demonstrated no moderator effect exists, neither the CRP interaction nor the reflection interaction terms entered into the regression model. Research Questions 4b and 4c were answered using stepwise hierarchical simple linear regression. The findings demonstrated that neither CRP nor reflection demonstrated a direct relationship with moral distress, whereas the independent variable CRP has a direct relationship with work engagement (R2 = .315, p = .002, b = .561). Research Question 5 Research Question 5 was answered using content analysis. Findings demonstrated the following three experiences had high response rates: (a) educationallearning experiences (100%, 28/28); (b) moral issue experiences (71%, 20/28); and (c) work-related experiences (68%, 19/28). This indicated participants were engaged with these experiences and desired to provide information that could be used to advance nursing knowledge. Findings for educational-learning experiences demonstrated there are three primary paths to learning: (a) practice-based, e.g., clinical time/“Hands on” (50%,
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14/28); (b) relationship based, e.g., preceptorship/ “Wow, I didn’t really feel prepared by school at all once I’d started on the floor. My preceptorship through the hospital was helpful” (25%, 7/28); and academic-based, e.g., class reviews/“Trauma Care, ACLS, PALS, BCLS, CPN . . . all prepare me to give the best possible care” (25%, 7/28). The analysis of moral issue experiences affirmed the validity of the MDS questionnaire, moral distress is clinically significant. Four major moral distress themes were identified: (a) death and suffering, e.g., futile care/“I frequently see situations where a patient’s life is being prolonged when morally and ethically it should not be” (35%, 7/20); (b) dealing with family, e.g., family clinging to hope when there is none/“It is hard in the NICU setting to deal with parents clinging to hope when there is none” (30%, 6/20); (c) medical versus nursing values, e.g., RNs are better prepared for patient’s death then a medical doctor (MD)/“I feel the nurses are prepared more for a patient’s death. I sometimes feel that patient’s lives are prolonged because the MDs see death as defeat and not a natural part of the human process. I feel that specialty doctors (renal, cancer, transplant, etc.) often fail to see the patient as a whole system, they are more concerned with certain numbers and labs and not others” (20%, 4/20); and (d) self-identification with the items on the not in the patient’s best interest MDS subscale/“They are common and stressful on staff” (15%, 3/20). Findings for work-related experiences demonstrated four primary work-related factors to examine: (a) role conflict in terms of management style or rules, e.g., designation of patient assignments/“way assignments are made, number of patients in assignment, acuity of pts and not just the number of pts assigned” (37%, 7/19); (b) moral distress, e.g., “The high level of stress in the ICU is exhausting and demoralizing. Most people outside the ICU do not understand the constant stress, lack of thanks, and physical exhaustion that comes with this job. Thus, something to assist nurses with a way to release stress, heal, and learn from the work about them would be excellent” (26%, 5/19); (c) physical distress, e.g., exhaustion/“The workload can be incredible and overwhelming many times. You feel like you have been beaten up by the time you leave. It is exhausting and I sometimes feel burnt out. And I’ve only been an RN for 2.5 years!” (21%, 4/19); and (d) relationships, e.g., development of close friendship bonds due to being together in life and death situations/“Close friendship bonds due to being together in life/death situations” (16%, 3/19).

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Critical Reflective Practice in Intensive Care Nurses
2. A positive direct relationship between CRP and work engagement. 3. Moral distress and CRP together explain a significant 47% of the variance in work engagement. 4. A positive direct relationship between increased education level an CRP in one unit only, e.g., NICU. 5. A suggested inverse relationship between education level and moral distress in one unit only, e.g., NICU, which warrants further study. In this study, two significant bivariate correlations were demonstrated: (a) CRP and work engagement were positively related; and (b) moral distress and work engagement were negatively related. This was the first study that demonstrated a positive relationship between CRP and work engagement. Obviously, further research will be necessary to confirm this study’s finding. However, it was a positive finding and it suggested that, as theoretically proposed, the affective, moral (or ethical), behavioral, cognitive, and political aspects associated with CRP were important to RNs work engagement. Specifically, this finding suggested that the CRP process contributes to the “optimal functioning and happiness of [nurses]” (De Lange et al., 2008, p. 201). In regards to clinical practice, it is recommended that practicing nurses, along with nursing and hospital leadership, promote CRP activities, e.g., promote activities which allow time for nurses to stoke and discuss conflicts between visions

Two primary “CRP” experiences were demonstrated, reflection as: (a) self-thought, e.g., agonizing about care by self/“mostly in my head; I tend to agonize over situations that could have done better” or “A lot while I’m lying in bed” (57%, 8/14); and (b) varied discussion, i.e., careful discussion with family/ friends, senior nurses, and attempts to suggest care to MDs/“I write about them or discuss (carefully) with friends and family” (29%, 4/14). The findings demonstrated a majority of reflection is done by self. Although there is no systematic approach to reflection, a discussion-approach to reflection is widely accepted. Some participants were found to agonize when thinking about work. Findings for Question 5e demonstrated an overall response rate of 11% (3/28). No identified themes in response were identified. Conclusion and Implications for Research and Practice Based upon a review of study findings, both statistically and clinically significant findings were demonstrated, and the theoretical model was revised accordingly. Figure 2 depicts the revised theoretical model. The revised model suggests the following: 1. A negative direct relationship between moral distress and work engagement.

Figure 2. Theoretical Model: Demonstrated Relationships Among Registered Nurses’ Educational Level, Moral Distress, Critical Reflective Practice, and Work Engagement. NICU, neonatal intensive care unit

Moral (r = -.48, p = .05) distress (r = -.61, p = NS) Work (NICU only) engagement (r = .56, p = .01) ↑ Educational level

Critical reflective practice

(R² = .47, p = .00)

( r = .78, p = .05) (NICU only)

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Critical Reflective Practice in Intensive Care Nurses for practice and practice as a lived reality, for such time may do much to promote engagement with work. A review of the literature suggests numerous CRPrelated activities: (a) reflective discussions between nurses and clinical nurse specialists (Peden-McAlpine et al., 2005); (b) provision of a space where RNs can meet to discuss clinical encounters (Wong, Kember, Chung, & Yan, 1995); (c) group activities in trusting environments, i.e., provide safe environments were RNs, as a group, can discuss both the cognitive and affective components of their practice (Paget, 2001; Ruth-Sahd, 2003); (d) adequate time for RNs to place clinical situations under a microscope, e.g., allow RNs to dissect clinical situations into various issues (Durgahee, 1998); (e) personal reflective diaries and regular meetings to discuss, as a group, the diary contents, e.g., weekly or bimonthly meetings (Durgahee, 1996); (f) regular multidisciplinary team-member meetings where all aspects of patient care are discussed (Åström, Jansson, Norberg, & Hallberg, 1993; Briggs, 1995); and (g) regular meetings of RNs with managers and/or supervisors, e.g., meet weekly on the unit to discuss care provision (McCaugherty, 1991). The identified negative bivariate correlation between moral distress and work engagement was also consistent with the proposed theoretical model and previous literature. According to previous studies, RNs who experienced moral distress were more likely to leave a position (Corley et al., 2001, 2005; Wilkinson, 1987/1988), leave (or consider to leave) the profession (Hamric & Blackhall, 2007; Millette, 1994), or implement the unsuccessful coping behavior of avoiding patients (Georges & Grypdonck, 2002; Gutierrez, 2005; Wilkinson, 1987/1988), all of which were demonstrative of decreased work engagement. A recommendation to reduce the negative outcomes of moral distress, including decreased work engagement as identified in this study, is for RNs in clinical practice to implement proven strategies to reduce moral distress: (a) RN storytelling (Nathaniel, 2006); (b) group gatherings to share and discuss ethical clinical happenings (Storch et al., 2002); (c) provision of support services so that RNs can talk about feelings (Åström et al., 1993; Raines, 2000; Verhaeghe et al., 2008); and (d) provision of continuing, in-house ethics education (Grady et al., 2008). At the unit level of analysis, in the NICU (n = 7), a statistically significant strong correlation between educational level and CRP was demonstrated. This finding, although not significant in the total sample, was consistent with the proposed theoretical model and
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previous literature, which suggested that an increased education level enhanced reflection (Duke & Appleton, 2000; Mountford & Rogers, 1996; Powell, 1989). Although a causal link between education level and CRP cannot be established with correlation data, the relationship between education level and CRP warrants further study. What is suggested is that increased RN education be promoted. An increase in RN education is related to an increase in CRP (in the NICU), and increased CRP demonstrates a direct relationship with increased work engagement (in the total sample). Because work engagement is worth promoting this data suggests increased RN education should be advocated. Furthermore, because of the non-significant but moderately large inverse relationship between increased education level and moral distress in the NICU, it is suggested that nurses and nurse leaders advocate for advanced nursing education. However, further study to examine the relationship between education level and moral distress is warranted. Study Limitations Sampling Two identified sampling limitations within this study were identified. First, the sample was nonrandomized, which makes generalization of the findings more difficult. Second, because the study’s sample size was small, there was increased potential not to achieve significance in the correlations. Again, this limits any generalization of findings that potentially could have resulted from this study. Instrumentation Another study limitation was the use of an unstandardized instrument, the CRPQ. However, the instrument demonstrated more than adequate reliability for a new instrument (above .80), and content validity was acceptable. In addition, the instrument correlated with all study variables as expected theoretically. Therefore, while continued testing is warranted, it was acceptable for use in this initial study. Implications for Future Research Future research will focus on further psychometric testing of the CRPQ, with testing and refinement of the theoretical model. The implementation of a CRP intervention is planned, to determine its relationship

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De Lange, A. H., De Witte, H., & Notelaers, G. (2008). Should I stay or should I go? Examining longitudinal relations among job resources and work engagement for stayers versus movers. Work and Stress, 22(3), 201– 223. Duke, S., & Appleton, J. (2000). The use of reflection in a palliative care programme: A quantitative study of the development of reflective skills over an academic year. Journal of Advanced Nursing, 32(6), 1557–1568. Durgahee, T. (1996). Promoting reflection in post-graduate nursing: A theoretical model. Nurse Education Today, 16, 419–426. Durgahee, T. (1998). Facilitating reflection: From a sage on stage to a guide on the side. Nurse Education Today, 18, 158–164. Eizenberg, M. M., Desivilya, H. S., & Hirschfeld, M. J. (2009). Moral distress questionnaire for clinical nurses: Instrument development. Journal of Advanced Nursing, 65(4), 885–892. Forchuk, C. (1991). Ethical problems encountered by mental health nurses. Issues in Mental Health Nursing, 12, 375–383. Fry, S. T., Harvey, R. M., Hurley, A. C., & Foley, B. J. (2002). Development of a model of moral distress in military nursing. Nursing Ethics, 9(4), 373–387. Georges, J. J., & Grypdonck, M. (2002). Moral problems experienced by nurses when caring for terminally ill people: A literature review. Nursing Ethics, 9(2), 155–178. Grady, C., Danis, M., Soeken, K. L., O’Donnell, P., Taylor, C., Farrar, A. et al. (2008). Does ethics education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8(4), 4–11. Greenwood, J. (1998). The role of reflection in single and double loop learning. Journal of Advanced Nursing, 27, 1048–1053. Gustafsson, C., Asp, M., & Fagerberg, I. (2007). Reflective practice in nursing care: Embedded assumptions in qualitative studies. International Journal of Nursing Practice, 13, 151–160. Gutierrez, K. M. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24(5), 229–241. Hamric, A. B., & Blackhall, L. J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 25(2), 422–429. Hart, S. E. (2005). Hospital ethical climates and registered nurses’ turnover intentions. Journal of Nursing Scholarship, 37(2), 173–177. Heath, H. (1998). Reflection and patterns of knowing in nursing. Journal of Advanced Nursing, 27(5), 1054–1059. Hefferman, P., & Heilig, S. (1999). Giving “moral distress” a voice: Ethical concerns among neonatal intensive care unit personnel. Cambridge Quarterly of Healthcare Ethics, 8, 173–178. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall. Johns, C. (2006). Becoming a reflective practitioner (2nd ed.). Malden, MA: Blackwell Publishing. Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for

with work engagement. For example, implementation of model of collaborative conversation, e.g., the “circle way” (Baldwin & Linnea, 2010), is planned for implementation with subsequent measurement of RN work engagement. Visit the Nursing Forum blog at http://www. respond2articles.com/NF/ to create, comment on, or participate in a discussion.
References Åström, G., Jansson, L., Norberg, A., & Hallberg, I. R. (1993). Experienced nurses’ narratives of their being in ethically difficult care situations: The problem to act in accordance with one’s ethical reasoning and feelings. Cancer Nursing, 16(3), 179–187. Bakker, A. B., Schaufeli, W. B., Leiter, M. P., & Taris, T. W. (2008). Work engagement: An emerging concept in occupational health psychology. Work and Stress, 22(3), 187– 200. Baldwin, C., & Linnea, A. (2010). The circle way: A leader in every chair. San Francisco, CA: Berrett-Koehler. Bell, J., & Breslin, J. M. (2008). Healthcare provider moral distress as a leadership challenge. Journal of Nursing Administration’s Law, Ethics, & Regulation, 10(4), 94–97. Briggs, C. A. (1995). Informed refusal and patient autonomy: Using reflection to examine how nursing knowledge and theory affect attitudes. Intensive & Critical Care Nursing, 11, 314–317. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological wellbeing. Journal of Personality and Social Psychology, 84(4), 822–848. Buerhaus, P. I. (2009). Current and future state of the U.S. nursing workforce. Journal of the American Medical Association, 300(20), 2422–2424. Buerhaus, P. I., Auerbach, D. I., & Staiger, D. O. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 28(4), 657–668. Clarke, S. P., & Connolly, C. (2004). Nurse education and patient outcomes: A commentary. Policy, Politics & Nursing Practice, 5(1), 12–20. Corley, M. C. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636– 650. Corley, M. S., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250–256. Corley, M. C., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12(4), 381–390. Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage. Cronqvist, A., Theorell, T., Burns, T., & Lützén, K. (2004). Caring about—caring for: moral obligations and work responsibilities in intensive care nursing. Nursing Ethics, 11(1), 63–76.

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Critical Reflective Practice in Intensive Care Nurses addressing the evolving nursing crisis. Retrieved December 19, 2008, from http://www.aacn.nche.edu/media/pdf/ JCAHO8-02.pdf Kälvemark, S., Höglund, A. T., Hansson, M. G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts: Ethical dilemmas and moral distress in the health care system. Social Science & Medicine, 58, 1075–1084. Kurtzman, E. T., & Corrigan, J. M. (2007). Measuring the contribution of nursing to quality, patient safety, and health care outcomes. Policy, Politics & Nursing Practice, 8(1), 20–36. Lang, K. R. (2008). The professional ills of moral distress and nurse retention: Education an antidote? American Journal of Bioethics, 8(4), 19–21. Liaschenko, J. (1995). Artificial personhood: Nursing ethics in a medical world. Nursing Ethics, 2(3), 185–196. Mauno, S., Kinnunen, U., & Ruokolainen, M. (2007). Job demands and resources as antecedents to work engagement: A longitudinal study. Journal of Vocational Behavior, 70, 149–171. McCaugherty, D. (1991). The use of a teaching model to promote reflection and the experiential integration of theory and practice in first-year student nurses: An action research study. Journal of Advanced Nursing, 16(5), 534– 543. Meltzer, L. S., & Huckabay, L. M. (2004). Critical care nurses’ perceptions of futile care and its effect on burnout. American Journal of Critical Care, 13, 202–208. Millette, B. E. (1994). Using Gilligan’s framework to analyze nurses’ stories of moral choice. Western Journal of Nursing Research, 16(6), 660–674. Mobley, M. J., Rady, M. Y., Verheijde, J. L., Patel, B., & Larson, J. S. (2007). The relationship between moral distress and perception of futile care in the critical care unit. Intensive & Critical Care Nursing, 23, 256–263. Mountford, B., & Rogers, L. (1996). Using individual and group reflection in and on assessment as a tool for effective learning. Journal of Advanced Nursing, 24, 1127–1134. Nathaniel, A. K. (2006). Moral reckoning in nursing. Western Journal of Nursing Research, 28(4), 419–438. Paget, T. (2001). Reflective practice and clinical outcomes: Practitioners’ views on how reflective practice has influenced clinical practice. Journal of Clinical Nursing, 10, 204– 214. Peden-McAlpine, C., Tomlinson, P. S., Forneris, P. S., Genck, G., & Meiers, S. J. (2005). Evaluation of a reflective practice intervention to enhance family care. Journal of Advanced Nursing, 49(5), 494–501. Powell, J. H. (1989). The reflective practitioner in nursing. Journal of Advanced Nursing, 14, 824–832. Raines, M. L. (2000). Ethical decision making in nurses: Relationships among moral reasoning, coping style, and ethics stress. Journal of Nursing Administration Healthcare Law, Ethics, and Regulation, 2(1), 29–41. Rice, E. M., Rady, M. Y., Hamrick, A., Verheijde, J. L., & Pendergast, D. K. (2008). Determinants of moral distress in medical surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management, 16, 360–373. Rolfe, G., & Gardner, L. (2006). “Do not ask who I am . . . ”: Confession, emancipation and (self)-management

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through reflection. Journal of Nursing Management, 14, 593–600. Rushton, C. H. (1995). The Baby K case: Ethical challenges of preserving professional integrity. Pediatric Nursing, 21(4), 367–372. Ruth-Sahd, L. A. (2003). Reflective practice: A critical analysis of data-based studies and implications for nursing education. Journal of Nursing Education, 42(11), 488–497. Schaufeli, W. B., & Bakker, A. (2004). Job demands, job resources, and their relationship with burnout and engagement: A multi-sample study. Journal of Organizational Behavior, 25, 293–315. Schaufeli, W. B., Salanova, M., González-Romá, V., & Bakker, A. B. (2002). The measurement of engagement and burnout: A two sample confirmatory factor analytic approach. Journal of Happiness Studies, 3, 71–92. Storch, J. L., Rodney, P., Pauly, B., Brown, H., & Starzomski, R. (2002). Listening to nurses’ moral voices: Building a quality health care environment. Canadian Journal of Nursing Leadership, 15(4), 7–16. Sundin-Huard, D., & Fahy, K. (1999). Moral distress, advocacy and burnout: Theorizing the relationships. International Journal of Nursing Practice, 5, 8–13. Taris, T., Cox, T., & Tisserand, M. (2008). Engagement at work: An emerging concept. Work and Stress, 22(3), 185– 186. Tate, S. (2004). Using critical reflection as a teaching tool. In S. Tate & M. Sills (Eds.), The development of critical reflection in the health professions (pp. 8–17, Chapter 1). London, UK: University of Westminster. Retrieved January 7, 2009, from http://www.health.heacademy.ac.uk/publications. occasionalpaper/occasionpaper04.pdf Teekman, B. (2000). Exploring reflecting thinking in nursing practice. Journal of Advanced Nursing, 31(5), 1125–1135. Trapnell, P. D., & Campbell, J. D. (1999). Private selfconsciousness and the five-factor model of personality: Distinguishing rumination from reflection. Journal of Personality and Social Psychology, 76(2), 284–304. United States Department of Health and Human Resources, Health Resources and Services Administration. (2010, March). The registered nurse population: Initial findings from the 2008 National Sample Survey of Registered Nurses. Retrieved July 29, 2010, from http://bhpr.hrsa.gov/ healthworkforce/rnsurvey/initialfindings2008.pdf Verhaeghe, R., Vlerick, P., De Backer, G., Van Maele, G., & Gemmel, P. (2008). Recurrent changes in the work environment, job resources and distress among nurses: A comparative cross-sectional survey. International Journal of Nursing Studies, 45, 382–392. Von Post, I. (1998). Perioperative nurses’ encounter with value conflicts. Scandinavian Journal of Caring Sciences, 12(2), 81–88. Wilkinson, J. W. (1987/1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16–29. Wong, K. Y., Kember, D., Chung, L. Y. F., & Yan, L. (1995). Assessing the level of student reflection from reflective journals. Journal of Advanced Nursing, 22, 48–57. Zuzelo, P. R. (2007). Exploring the moral distress of registered nurses. Nursing Ethics, 14(3), 344–359.

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