iMOD

Inventory of Moral Distress

Problem Statement

Moral Distress occurs when an individual’s moral integrity is seriously compromised, either because one feels unable to act in accordance with core values and obligations, or attempted actions fail to achieve the desired outcome. Dr. Lucia Wocial, an Ethicist Nurse Researcher and our capstone project sponsor aims in providing a healthy environment where critical care nurses make their optimal contributions to patients and families. In this attempt, they are looking to develop a digital solution which will enable the nurses to record the level of distress along with the cause they have been experiencing during the past week.

There are many contributing factors to this feeling of Moral Distress such as Clinical Triggers, Internal Factors, Communication and Interpersonal issues, Institutional and Environmental factors, Legal and Regulatory factors etc. Dr. Lucia's research combines ethics and distress amongst the nurse community and studies their implications on the behavior. Our initial meetings with her shaped our understanding of the problem space. To dig more, we reviewed more research papers that Dr. Lucia provided us and we reviewed a few on our own to understand where the technology stand in helping address the stress issues.

Interviews

Placeholder image: Need to redesign this

Meetings with Dr. Lucia and the literature review done in the initial phase gave us the business requirements. On the basis of that, we designed our interview sessions. This was a phase of discovery for us as a team. We decided to go with semistructured interviews along with a survey to gather usage of technology and what are the major contributing factors towards Moral Distress. Also, one of the question we deliberately added to the survey was to understand if the nurses are willing to share their experience with others. We were taken aback by their experiences when they felt moral distress. How much pain they go through on some of the days and we are so ignorant about it. Some of the insights that we got from this data gathering technique were quite surprising and completely opposite to Dr. Lucia's research

Insights from interview survey results

Every nurse we interviewed was willing to share his/her experience with another nurse, nurse manager, friend or a family member
They would like to record the Moral Distress level as soon as they feel it, all they could think a handy way would be a mobile app
They would like to receive help for their Moral Distress and learn to deal with it

100% users feel Moral Distress

All the users we interviewed mentioned that every critical care unit nurse feels some level of moral distress no matter what the level of his/her professional experience is

50% users want to change the profession

Due to the constant turnover and additional shift hours along with the moral distress, 50% of the Nurses want to either change the job or leave the profession entirely.

100% users want to share it with someone

Nurses prefer sharing information with their a small set of close peers who are considered as friends

Making Sense of the Research Data

We conducted Affinity Diagramming session to make sense of the interview data. It gave us different categories for Nurse and Nurse Manager profile separately. e.g. For Nurse Persona, we found out the reasons for Moral Distress, ways to cope up with it, concerns they have.

Identify Moral Distress

Address Moral Distress

Nurse Manager Concerns

For Nurse Manager Persona, how would the Nurse Managers identify if a nurse is experiencing Moral Distress and not just stress, how do they address or provide help to nurses so that they can cope up with it. Even Nurse Managers had concerns for the tools to cope up or record. They had great suggestions for us on how they want to see the aggregate score of moral distress in a particular unit.

Mental Model of Critical Care Unit Nurses

Next step was to create a model which will lead us to our three concepts of problem solution. We chose mental model diagramming to understand our users' motivation to use the system or app. What do they presently do when they experience Moral Distress, what are the different hurdles they face, how system helps them cope up with it. It guided us to our three concepts of solutions to the problem. It gave us the direction in visioning our solution.

Concept Design

Based on American Association of Critical-Care Nurses (AACN) 4 A's Model, we created solutions for three different categories:

A Strategic solution: No usage of technology
Semi-Strategic Solution: Partial use of technology
Technology based solution

Strategic Solution

Physical Board in the Nurse Break Room where they can record their moral distress, view cope-up techniques, and add a Thank-You note to express gratitude towards them who helped them cope up with it

Semi-strategic Solution

A discreet corner with a headset that senses the stress level and guides the user to record, and cope up with the moral distress with a humanized approach

Technology Solution

This concept drove our mobile app prototype. We also ideated for future iterations on some wearable technology concepts

Features

While experiencing moral distress, subjecting nurses immediately to recommended strategy would benefit them less versus asking them to take a step back and relax before performing the recommended intervention. Following are the main functions of the final concept:

1. Meter: Allows nurses to record their level of moral distress from the three levels “mild”, “moderate”, “severe” and select the factors contributing to a particular level of distress.

2. Strategy: Suggests interventions such as “mindfulness”, “coloring”, “physical activities” and also tracks the level of moral distress after performing a certain strategy.

3. Huddle: Social platform within the hospital boundaries for nurses to chat with their peers, charge nurses, nurse managers and nurse ethicist. It also allows the nurses to create groups for discussing a pressing situation or share some important information with a set of people.

4. Profile: Allows nurses to update their personal information and track progress of the strategies performed in the past to benefit from them in the future.

Wireframes

Using Balsamiq, we created Low-fidelity mockups. We were able to a demonstrate our designs to our Mentor who is a Nurse Ethicist, a Nurse Educator, a Nurse Program Manager and a Shift Coordinator. Their initial feedback gave us a few directions for our high-fidelity prototype. However, they were quite happy to see the shape of their imagination. Putting up the Low-fidelity prototypes of the three important concepts

Hi-Fidelity Prototype

After iterating over our low-fidelity prototypes, we included all the suggestions that we received from the stakeholders. We created workflow and we realized that there are a few screens that need to be included. We included everything in out high-fidelity prototype created with Axure RP. This is still work in progress. We will soon be evaluating our prototype to get feedback on our designs from Nurses. Dr. Lucia is curious to know the cost involved in developing the prototype into a product. It is a great opportunity for us as students to work on the estimates, so we know what exactly happens in the real world when we design.

Meter

Nurse records his/her Moral Distress level and contributing factors. A summary screens to review their selection, and may change any of the input by going back to the relevant meter screen. We designed three crisis management screens of 5 seconds each to calm them down momentarily.

Strategies

As the AACN 4 A's Model suggests we assess and ask them to act on it. So we suggested them to take up a few intervention strategies of 5 minutes each e.g. Meditation, Adult coloring etc. We again take the feedback from them if they feel any better at that moment after taking up the activity. If not we ask them if they would like to take up any other activity and navigate them accordingly. If not we suggest them to talk to someone and suggest a list of appropriate people to talk to. If they choose one from the list, we open up a channel to chat with that person.

Intervention Strategies: Take a deep breath, smile, stand-up, and take a quick walk

Options to choose from other cope-up mechanisms

Meditation

Record the level again

Huddle and Profile

Huddle is a chat feature that allows them to share their experience with their hospital contacts and get help. When they establish a chat with another Nurse or Nurse Ethicist, we tell them about the Moral Distress Level and the contributing factors the Nurse has chosen in Meter.

Profile feature helps the Nurse to track her Moral Distress level and what strategies helped him/her to cope up with it. Nurses can edit the information about them, so that they have better options for interventions based on their interests.

User Evaluation

We recruited 6 participants for User Testing. We conducted cognitive walkthrough with our first participant nurse considering her Domain Expertise. It helped us review and revise the workflows and interactions. We iterated over the prototype to accommodate the suggestions of our Domain Expert. With other participants we conducted test on the refined prototype. We asked them to rate the app based on the intuitiveness and appearance for each feature. The results proved that we need very little improvements in the interactions and content. Some workflows will be improved based on Dr. Wocial's inputs.

Demographics

Future Work

iMOD application has great potential to assist nurses to navigate the emotional components of the experience of moral distress. The app will help the nurses to be heard in times of distress and take-up short treatment strategies recommended for their well-being. With minimum exposure to use of technology during their entire day the app allows nurses to utilize the time they could take off from work and indulge in the activities that helps to relax.

For Nurses:

Currently, the app requires few refinements that were suggested during the usability evaluation sessions by the nurses to make it more effective. Further work is needed to develop the app to assist with navigating the ethical challenges that led to the feelings of distress.

For Nurse Managers:

Nurse Managers profile and aggregating the moral distress data in the form of data visualization for them is also one of the potential areas of future development. Website for nurse managers would leverage the effectiveness of the iMoD app and both together would helps the nurse and the nurse managers to deal with the problem of moral distress efficiently. We planned to develop the website for Nurse Managers to see the aggregate Moral Distress Levels of a Nursing Unit and track the progress of individual Nurse. Also, a wearable app design based on the notification of the Sever Moral Distress Level in each of the unit

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