Moral Distress in Pediatric Healthcare Providers

Participatory management effects on nurses' organizational support and moral distress

RESEARCH QUESTION/AIM/OBJECTIVES

Providing care for hospitalized children causes moral distress to nurses. Employee participation in discovering and solving the everyday problems of the workplace is one of the ways to hear the voices of nurses. This study aimed to evaluate the effect of participatory management programs on perceived organizational support and moral distress in pediatric nurses.

RESEARCH DESIGN

A quasi-experimental study.

PARTICIPANTS AND RESEARCH CONTEXT

The present study was conducted on 114 pediatric nurses in Iran. Data were collected using the Perceived Organizational Support Scale and the Moral Distress Scale of nurses. The intervention included implementing a participatory management program in three treatment departments that were randomly selected and it lasted 4 months. Participatory management was at the level of problem-solving with a focus on investigating, solving, and correcting issues and problems of work shifts and departments concerning the physical environment, equipment of the department, improvement of work processes, and team cooperation. In the control group, ordinary organizational approaches to problem-solving were used.

ETHICAL CONSIDERATIONS

This study was approved by the Ethics Committee of Mashhad School of Nursing and Midwifery. Informed consent was obtained from the study participants.

FINDINGS/RESULTS

Based on the results, both groups were homogenous before the intervention in terms of moral distress and perceived organizational support. The results showed that the moral distress mean scores in the intervention group decreased from 1.45 (0.52) to 1.03 (0.37) after the intervention. Also, the score of the perceived organizational support was 2.12 (1.2) increased after the intervention to 2.68 (1.10) in the intervention group.

CONCLUSIONS

It was found that the participation of nurses in the problem-solving process to solve daily workplace issues can be effective in increasing their perceived organizational support and reducing their moral distress.

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation

OBJECTIVE

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence.

HYPOTHESIS

Moral distress will be significant in a dedicated pediatric trach/vent unit.

METHODS

The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed.

RESULTS

Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively).

CONCLUSIONS

Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

The moral deliberation pathway in veterinary practice: a qualitative study

BACKGROUND

Veterinarians may face various ethical decisions and potential moral conflicts in clinical practice. The ethical decision-making process often leads to a satisfying resolution. However, when such a process is accompanied by a perceived inability to act according to a person's values, it can lead to psychological distress that characterises moral distress. Theoretical models in professions such as nursing attempt to explain the evolution of moral conflict into moral distress. In veterinary professionals, a model has been proposed to explain this pathway (the moral deliberation pathway). However, empirical data are still lacking on whether veterinary clinicians experience a moral deliberation pathway as hypothesised.

METHODS

Using thematic analysis, this qualitative study investigates veterinary clinicians' experiences with moral distress and aims to explain the moral deliberation pathway in these veterinarians.

RESULTS

The results suggest that veterinarians' experiences with moral distress follow a deliberation process that can be explained by the proposed moral deliberation pathway. Experiencing a moral conflict leads to moral stress, then either to moral distress or resolution into moral comfort.

LIMITATIONS

Self-selection of participants and possible recollection bias may have biased the findings.

CONCLUSIONS

The empirical data provided by this study can inform future research and intervention strategies to identify, measure and manage moral distress in the veterinary context.

Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel

OBJECTIVES

To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs.

PARTICIPANTS

The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs.

DESIGN/METHODS

We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies.

RESULTS

The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated.

CONCLUSIONS

These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.

A Qualitative Study of Nurses' Perspectives on Neonatologist Continuity of Care

BACKGROUND

Families and staff in neonatal intensive care units (NICUs) value continuity of care (COC), though definitions, delivery, and impacts of COC are incompletely described. Previously, we used parental perspectives to define and build a conceptual model of COC provided by neonatologists. Nursing perspectives about COC remain unclear.

PURPOSE

To describe nursing perspectives on neonatologist COC and revise our conceptual model with neonatal nurse input.

METHODS

This was a qualitative study interviewing NICU nurses. The investigators analyzed transcripts with directed content analysis guided by an existing framework of neonatologist COC. Codes were categorized according to previously described COC components, impact on infants and families, and improvements for neonatologist COC. New codes were identified, including impact on nurses, and codes were classified into themes.

RESULTS

From 15 nurses, 5 themes emerged: (1) nurses validated parental definitions and benefits of COC; (2) communication is nurses' most valued component of COC; (3) neonatologist COC impact on nurses; (4) factors that modulate the delivery of and need for COC; (5) conflict between the need for COC and the need for change. Suggested improvement strategies included optimizing staffing and transition processes, utilizing clinical guidelines, and enhancing communication at all levels. Our adapted conceptual model describes variables associated with COC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Interdisciplinary NICU teams need to develop systematic strategies tailored to their unit's and patients' needs that promote COC, focused to improve parent-clinician communication and among clinicians. Our conceptual model can help future investigators develop targeted interventions to improve COC.

Turkish Adaptation of the Moral Distress Scale-Revised for Pediatric Nurses: A Validity and Reliability Study

Background and Purpose: Recent studies have demonstrated the adverse effects that moral distress experienced by nurses has on nurses, patients, and the healthcare system. This study aims to analyze the validity and reliability of the Turkish version of the Moral Distress Scale-Revised (MDS-R, pediatric). Methods: This study was conducted with 210 pediatric nurses. Results: Explanatory factor analysis was conducted, and a five-factor structure emerged. The Cronbach's α value of the scale was found to be 0.865, and the correlation-based item analysis showed that the values were within the acceptable range, and the discrimination of the items was adequate. Conclusions: Analyses conducted revealed that the Turkish version of the MDS-R (pediatric), consisting of 21 items and five subdimensions, is a valid and reliable measurement tool for the Turkish culture and language.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs

OBJECTIVES

To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived.

DESIGN

A cross-sectional survey.

SETTING

U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships.

SUBJECTS

One senior physician and one senior nurse at each institution.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility.

CONCLUSIONS

Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

Influence of spirituality on moral distress and resilience in critical care staff: A scoping review

OBJECTIVE

The Covid 19 pandemic has created a situation in which critical care staff experience moral distress. For reducing moral distress, resources such as spirituality can be used. The aim of this scoping review is to explore whether spirituality mitigates the moral distress of critical care staff and strengthens their resilience. The spiritual resources will be identified and the ability of the staff to use spiritual resources will be explored.

METHODOLOGY

A scoping review of studies reporting on the association between spirituality, moral distress, and resilience. Qualitative and quantitative studies from 2020 that examined critical care staff are included. This scoping review used the five-step framework proposed by Arksey and O'Malley and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for scoping reviews. The literature searches were conducted in 12 databases.

RESULTS

13 studies met inclusion criteria. Critical care staff declaring themselves as spiritual have a higher risk of moral distress and are often not able to use spiritual resources on their own. For effective use of spiritual resources to reduce moral distress, staff need to be skilled in the practice of spirituality with the aim to find inner peace, focus on the positive, and regain a sense of purpose in the work.

CONCLUSION

Spirituality does not automatically help the critical care staff to cope with moral distress and strengthen resilience. Institutions need to create conditions in which the critical care staff are supported to use their spiritual resources.

IMPLICATION FOR CLINICAL PRACTICE

Institutions need to involve staff more in the design, implementation, and delivery of spiritual interventions to minimise moral distress. Further research is necessary to examine the impact of critical care staff's demographic characteristics on their spirituality, moral distress, and resilience.

A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity

Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.

Effect of a Moral Distress Consultation Service on Moral Distress, Empowerment, and a Healthy Work Environment

BACKGROUND

 Healthcare providers who are accountable for patient care safety and quality but who are not empowered to actualize them experience moral distress. Interventions to mitigate moral distress in the healthcare organization are needed.

OBJECTIVE

 To evaluate the effect on moral distress and clinician empowerment of an established, health-system-wide intervention, Moral Distress Consultation.

METHODS

 A quasi-experimental, mixed methods study using pre/post surveys, structured interviews, and evaluation of consult themes was used. Consults were requested by staff when moral distress was present. The purpose of consultation is to identify the causes of moral distress, barriers to action, and strategies to improve the situation. Intervention participants were those who attended a moral distress consult. Control participants were staff surveyed prior to the consult. Interviews were conducted after the consult with willing participants and unit managers. Moral distress was measured using the Moral Distress Thermometer. Empowerment was measured using the Global Empowerment Scale.

RESULTS

 Twenty-one consults were conducted. Analysis included 116 intervention and 30 control surveys, and 11 interviews. A small but significant decrease was found among intervention participants, especially intensive care staff. Empowerment was unchanged. Interview themes support the consult service as an effective mode for open discussion of difficult circumstances and an important aspect of a healthy work environment.

CONCLUSIONS

 Moral distress consultation is an organization-wide mechanism for addressing moral distress. Consultation does not resolve moral distress but helps staff identify strategies to improve the situation. Further studies including follow up may elucidate consultation effectiveness.

Estimation of moral distress among nurses: A systematic review and meta-analysis

BACKGROUND

Moral distress is a common challenge among professional nurses when caring for their patients, especially when they need to make rapid decisions. Therefore, leaving moral distress unconsidered may jeopardize patient quality of care, safety, and satisfaction.

AIM

To estimate moral distress among nurses.

METHODS

This systematic review and meta-analysis conducted systematic search in Scopus, PubMed, ProQuest, ISI Web of Knowledge, and PsycInfo up to end of February 2022. Methodological quality of included studies was assessed using the Newcastle Ottawa checklist. Data from included studies were pooled by meta-analysis with random effect model in STATA software version 14. The selected key measure was mean score of moral distress total score with its' 95% Confidence Interval was reported. Subgroup analyses and meta-regressions were conducted to identify possible sources of heterogeneity and potentially influencing variables on moral distress. Funnel plots and Begg's Tests were used to assess publication bias. The Jackknife method was used for sensitivity analysis.

ETHICAL CONSIDERATION

The protocol of this project was registered in the PROSPERO database under decree code of CRD42021267773.

RESULTS

Eighty-six manuscripts with 19,537 participants from 21 countries were included. The pooled estimated mean score of moral distress was 2.55 on a 0-10 scale [95% Confidence Interval: 2.27-2.84, I²: 98.4%, Tau²:0.94]. Publication bias and small study effect was ruled out. Moral distress significantly decreased in the COVID-19 pandemic versus before. Nurses working in developing countries experienced higher level of moral distress compared to their counterparts in developed countries. Nurses' workplace (e.g., hospital ward) was not linked to severity of moral disturbance.

CONCLUSION

The results of the study showed a low level of pooled estimated score for moral distress. Although the score of moral distress was not high, nurses working in developing countries reported higher levels of moral distress than those working in developed countries. Therefore, it is necessary that future studies focus on creating a supportive environment in hospitals and medical centers for nurses to reduce moral distress and improve healthcare.

Moral Distress Under Structural Violence: Clinician Experience in Brazil Caring for Low-Income Families of Children with Severe Disabilities

Rigorous attention has been paid to moral distress among healthcare professionals, largely in high-income settings. More obscure is the presence and impact of moral distress in contexts of chronic poverty and structural violence. Intercultural ethics research and dialogue can help reveal how the long-term presence of morally distressing conditions might influence the moral experience and agency of healthcare providers. This article discusses mixed-methods research at one nongovernmental social support agency and clinic in Rio de Janeiro, Brazil. Chronic levels of moral distress and perceptions of moral harm among clinicians in this setting were both violent, following Nancy Scheper-Hughes' use of that term, and a source of exceptional and innovative care. Rather than glossing over the moral variables of work in such desperate extremes, ethnography in these settings reveals novel skills and strategies for managing moral distress.

Perceived Benefits of Ethics Consultation Differ by Profession: A Qualitative Survey Study

BACKGROUND

There are numerous benefits to ethics consultation services, but little is known about the reasons different professionals may or may not request an ethics consultation. Inter-professional differences in the perceived utility of ethics consultation have not previously been studied.Methods: To understand profession-specific perceived benefits of ethics consultation, we surveyed all employees at an urban tertiary children's hospital about their use of ethics committee services (n = 842).Results: Our findings suggest that nurses and physicians find ethics consultations useful for different reasons; physicians were more likely to report normative benefits, while nurses were more likely to report communicative and relational benefits.Conclusions: These findings support an open model of ethics consultation and may also help ethics committees to better understand consultation requests and remain attuned to the needs of various professional groups.

Healthcare quality during pediatric mental health boarding: A qualitative analysis

BACKGROUND

Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period.

OBJECTIVE

This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts.

DESIGN, SETTING, & PARTICIPANTS

We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development.

RESULTS

Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress.

CONCLUSION

This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population.

Systematic scoping review on moral distress among physicians

BACKGROUND

Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians.

METHODS

A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows.

RESULTS

A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions.

CONCLUSIONS

Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy

Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.

A systematic scoping review moral distress amongst medical students

BACKGROUND

Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students.

METHODS

The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion.

RESULTS

Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD.

CONCLUSIONS

MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

Objective Personality Determination: A Useful Addition to the Traditional Process of Pediatric Surgical Fellow Selection

BACKGROUND

Selection of pediatric surgical trainees is a multifaceted process heavily influenced by in-person interviews to determine personality makeup and institutional compatibility. We present our experience in utilizing a validated personality inventory in the selection of our candidates.

METHODS

All applicants selected for an in-person interview for the 2020 Pediatric Surgery Match were offered the Big Five Inventory (BFI) questionnaire. An initial rank order list (ROL) was formulated employing application information and in-person interview score. A reformulated ROL was created after incorporating BFI data. Correlation of specific personality characteristics vs position on the ROL was assessed for both the initial ROL and the reformulated ROL.

RESULTS

Thirty-four applicants were interviewed and 24 (70.6%) were ranked. Linear regression analysis identified a lower neuroticism score directly related to a higher position on the initial ROL {R = .4626, P = .023}. The reformulated ROL identified a higher conscientiousness score {R = .5331; P = .007} and a lower neuroticism score {R = -.4383; P = .032} correlated with ascending the final ROL.

CONCLUSIONS

The self-administered BFI adds objectivity to personality determination gleamed from the standard face-to-face interview. Conscientiousness and neuroticism had a significant impact on the final ROL position. Adding objective personality data appears to provide additional aid in this difficult process.

Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center

BACKGROUND

Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave.

METHODS

We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.

RESULTS

Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001).

CONCLUSIONS

Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study

OBJECTIVES

The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence.

STUDY DESIGN

We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules.

RESULTS

Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas.

CONCLUSIONS

After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized-half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.

Moral Distress in Healthcare Providers Who Take Care of Critical Pediatric Patients throughout Italy-Cultural Adaptation and Validation of the Italian Pediatric Instrument

Background: Although Moral Distress (MD) is a matter of concern within the Pediatric Intensive Care Unit (PICU), there is no validated Italian instrument for measuring the phenomenon in nurses and physicians who care for pediatric patients in Intensive Care. The authors of the Italian Moral Distress Scale-Revised (Italian MDS-R), validated for the adult setting, in 2017, invited further research to evaluate the generalizability of the scale to clinicians working in other fields. Our study aims to reduce this knowledge gap by developing and validating the pediatric version of the Italian MDS-R. Methods: We evaluated the new instrument for construct validity, then we administered it in a multicenter, web-based survey that involved healthcare providers of three PICUs and three adult ICUs admitting children in northern, central, and southern Italy. Finally, we tested it for internal consistency, confirmatory factorial validity, convergent validity, and differences between groups analysis. Results: The 14-item, three-factor model best fit the data. The scale showed good reliability (a = 0.87). Still, it did not correlate with the Emotional Exhaustion and Depersonalization sub-scales of the Maslach Burnout Inventory (MBI) or with the 2-item Connor-Davidson Resilience Scale (CD-RISC 2) or the Satisfaction with Life Scale (SWLS). A mild correlation was found between the Italian Pediatric MDS-R score and intention to resign from the job. No correlation was found between MD and years of experience. Females, nurses, and clinicians who cared for COVID-19 patients had a higher MD score. Conclusions: The Italian Pediatric MDS-R is a valid and reliable instrument for measuring MD among Italian health workers who care for critically ill children. Further research would be helpful in better investigating its applicability to the heterogeneous scenario of Italian Pediatric Critical Care Medicine.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

Moral distress interventions: An integrative literature review

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Experience of Pediatric Patient Death, Moral Distress, and Turnover Intention among Pediatric Nurses at a Tertiary Hospital in South Korea: A Cross-Sectional Study

Background: Pediatric nurses are particularly vulnerable to moral distress and turnover due to frequent experiences with patient death combined with limited pediatric palliative resources and related support. Objective: This study examined pediatric nurses' experiences of pediatric patient death, moral distress, and turnover intention and identified the correlations between them as well as the mediating role of moral distress. Methods: This cross-sectional study conducted an online survey with 161 pediatric nurses working in a tertiary hospital in Seoul, South Korea. The survey comprised questions to assess nurses' experience of pediatric patient death and turnover intention and a validated instrument to measure their moral distress. Logistic regression was used to examine the relationships between study variables, and structural equation modeling was performed to determine the mediating effect of moral distress. Results: Pediatric nurses (N = 161) reported high levels of moral distress with a mean score of 101.06 (standard deviation = 70.528) on the pediatric version of the Moral Distress Scale. Turnover intention increased 1.01 times for every 1 U increase in moral distress. Moral distress fully mediated the relationship between the experience of pediatric patient death and turnover intention. Conclusion: Pediatric patient death had an indirect effect on turnover intention through moral distress among pediatric nurses. Reducing pediatric nurses' moral distress caused from experiencing patient death may help minimize their turnover intention.

Moral distress among Iranian neonatal intensive care units' health care providers: a multi-center cross sectional study

Due to the unique nature of the neonatal intensive care unit (NICU) and its moral distress, this study aimed to investigate moral distress in the NICU. This cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. The Corley’s Moral Distress Scale was used to collect data. Findings showed that 25 of the participants were physicians and 209 were nurses. The intensity and frequency of distress among physicians and nurses were assessed as moderate. The mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. The results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. The intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. Moral distress in the NICU practitioners was moderate, so addressing this issue and trying to alleviate it was important. Identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them.

The Nurse Manager's Experience of Moral Distress

The purpose of this study was to describe the moral distress experiences of nurse managers. Moral distress has been studied among direct patient care providers including nurses and physicians. The moral distress experience among nurse managers is less understood. We conducted a qualitative descriptive study with 19 nurse managers from 5 healthcare institutions in Virginia. Interview data were analyzed using a directed content analysis, as the structural components of the moral distress phenomenon are already known. Participants suffered moral distress when they were unable to achieve or maintain effective unit function and felt caught in the middle between their units' and employees' needs and organizational directives. System-level causes of moral distress are common among nurse managers. Future research should involve measurement of moral distress among nurse managers and exploration of effective interventions.

The impact of interprofessional perspective-taking on moral distress in the pediatric intensive care unit

Moral distress arises when constraints outside of healthcare professionals' control prohibit them from acting according to the ethically sound course of action. It can be triggered by poor communication and different perspectives between professionals. We examined whether and how taking the perspective of the other profession reduces moral distress among pediatric intensive care nurses and physicians. Using elements of a previously published scale, we created a Vignette-based Moral Distress Rating Scale (V-MDRS). Study participants from three sites included 105 nurses and 34 physicians who read a patient vignette with their own profession's perspective, completed the V-MDRS, then received the other profession's perspective and completed the V-MDRS again. We conducted semi-structured interviews with nine nurses and nine physicians who completed the V-MDRS to explore how interprofessional perspective-taking impacts moral distress. Nurses experienced higher baseline moral distress than physicians (mean ± standard deviation 31.1 ± 6.9 vs 26.4 ± 5, P < .001), and at two study sites nurses' moral distress declined after reading the physician's perspective. Findings from interviews suggest that physicians were already sensitized to nurses' perspective and that perspective-taking may be particularly beneficial to cohesive teams with strong relationships. Thus, encouraging interprofessional perspective-taking may mitigate moral distress in healthcare professionals.

Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community

Burnout incurs significant costs to health care organizations and professionals. Mattering, moral distress, and secondary traumatic stress are personal experiences linked to burnout and are byproducts of the organizations in which we work. This article conceptualizes health care organizations as moral communities-groups of people united by a common moral purpose to promote the well-being of others. We argue that health care organizations have a fundamental obligation to mitigate and prevent the costs of caring (eg, moral distress, secondary traumatic stress) and to foster a sense of mattering. Well-functioning moral communities have strong support systems, inclusivity, fairness, open communication, and collaboration and are able to protect their members. In this article, we address mattering, moral distress, and secondary traumatic stress as they relate to burnout. We conclude that leaders of moral communities are responsible for implementing systemic changes that foster mattering among its members and attend to the problems that cause moral distress and burnout.

Moral distress among nurses: A mixed-methods study

BACKGROUND

Moral distress is recognized as a problem affecting healthcare professionals globally. Unaddressed moral distress may lead to withdrawal from the moral dimensions of patient care, burnout, or leaving the profession. Despite the importance, studies related to moral distress are scant in Thailand.

OBJECTIVE

This study aims to describe the experience of moral distress and related factors among Thai nurses.

DESIGN

A convergent parallel mixed-methods design was used. The quantitative and qualitative data were collected in parallel using the Measure of Moral Distress for Healthcare Professionals and interview guide. The analysis was conducted separately and then integrated.

PARTICIPANTS

Participants were Thai nurses from two large tertiary care institutions in a Southern province of Thailand.

ETHICAL CONSIDERATIONS

This study was approved by our organization's Institutional Review Board for Health Sciences Research, and by the Institutional Review Boards of the two local institutions in Thailand. Permission from the publisher was received to translate and utilize the Measure of Moral Distress (MMD-HP) under the license number: 4676990097151.

RESULTS

A total of 462 participants completed the survey questions. The top 7 causes of moral distress were related to system-level root causes and end-of-life care situations. Hierarchical multiple regression showed that work units, considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. Twenty interviews demonstrated three main themes of distressing causes: (1) powerlessness (at patients/family-, team-, and organizational-levels), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetent healthcare providers, and inappropriate behavior of colleagues). The integration of data from both components indicated that the qualitative interviews enrich the quantitative findings, especially as related to the top 7 causes of moral distress.

DISCUSSION

Although the experience of moral distress among Thai nurses is similar to studies conducted elsewhere, the patient's and family's religious perspective that ties into the concept of moral distress needs to be explored.

CONCLUSIONS

Although the root causes of moral distress are similar among different cultures, the experience of Thai nurses may vary according to culture and context.

Development and Retrospective Review of a Pediatric Ethics Consultation Service at a Large Academic Center

The primary objective was to review pediatric ethics consultations (PECs) at a large academic health center over a nine year period, assessing demographics, ethical issues, and consultant intervention. The secondary objective was to describe the evolution of PECs at our institution. This was a retrospective review of Consultation Summary Sheets compiled for PECs at our Academic Health Center between January 2008 and April 2017. There were 165 PECs reviewed during the study period. Most consult requests came from the inpatient setting, with the Pediatric and Neonatal Intensive Care Units being the highest utilizers. Consultation utilization increased over the study period. The most common patient age was less than one year. Physicians were most likely to request consultation. Patient Best Interest, Withholding/Withdrawing of Life Sustaining Therapy, and Provider Moral Distress were ethical issues most commonly identified by the consultants. Making recommendations was the most common consultant intervention. The ethics consultation process evolved over time from informal provider discussions, to a hospital infant care review committee, to a pediatric only consultation service, to a combined adult/pediatric consultation service, with variable levels of salary support for consultants. Ethics consultation requests are growing at our institution. Similarities in identified ethical issues exist between our findings and existing literature, however meaningful comparisons remains elusive secondary to variability in approaches to investigation and reporting. A combined paid/volunteer/trainee ethics consultation service model appears sustainable and real time ethics consultation is feasible using this approach.

Evaluation of NICU Healthcare Providers' Experience of Patient Ethics and Communication Excellence (PEACE) Rounds

BACKGROUND

Neonatal intensive care (NICU) providers may experience distress due to controversial orders or the close relationships they form with neonates' families. A "Patient Ethics and Communications Excellence [PEACE] Rounds" intervention developed at Indiana University proved to significantly relieve distress by facilitating interdisciplinary discussions of clinically and ethically challenging issues associated with pediatric intensive care (PICU) patient care. NICU healthcare providers face similar challenges and will benefit from understanding the potential efficacy of PEACE Rounds in this setting.

PURPOSE

This study describes the experiences of NICU healthcare providers who participate in PEACE Rounds and evaluates their perceptions of how it affects their distress levels, contributes to interdisciplinary collaboration, and influences their understanding of ethical decision-making.

METHODS

Researchers conducted semi-structured interviews with 24 intervention participants, observed 12 interventions, facilitated a validation focus group, and performed a constructionist thematic analysis and triangulation based on data from transcribed recordings.

FINDINGS

PEACE Rounds improved interdisciplinary communication and collaboration and demonstrated restorative value through the benefits of voice and collective support. The intervention may reduce, but not replace, the need for formal ethics consultations.

IMPLICATIONS FOR PRACTICE

PEACE Rounds may potentially improve interdisciplinary communications and collaboration, relieve employee distress, and reduce ethics consultations.

IMPLICATIONS FOR RESEARCH

Studies of PEACE Rounds undertaken in other clinical settings, and facilitated by a nurse educator, will help assess the potential benefits of greater reach and access and the efficacy of less structured ethics discussions.

Ethical climate in contemporary paediatric intensive care

Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.

Moral distress in pediatric otolaryngology: A pilot study

OBJECTIVES

SUBJECTS/METHODS: Moral distress is defined as "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action". The Moral Distress Survey-Revised (MDS-R) is a validated 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to pediatric otolaryngology faculty and fellows at a tertiary institution. Descriptive statistics, bivariate and multivariate analysis were performed.

RESULTS

Response rate was 89% (16/18). Overall MDS-R score was 40 (range 14-94), which is lower than that found in the literature for pediatric surgeons (reported mean 72), pediatric intensivists (reported means 57-86), and similar to pediatric oncologists (reported means 42-52). Fellows had a significantly higher level of moral distress than faculty (mean 69 vs. 26, p < 0.05). Factors leading to higher degrees of distress involved communication breakdowns and pressure from administration/insurance companies to reduce costs.

CONCLUSION

Pediatric Otolaryngologists at our institution have lower degrees of moral distress compared to other pediatric subspecialists. Fellows had higher levels of distress compared to faculty. Further research is necessary to determine degrees of distress across institutions and to determine its impact on the wellness of pediatric otolaryngologists.

Health Care Professionals' Experiences of Providing Care to Hospitalized Medically Fragile Infants and Their Parents

PURPOSE

To understand contemporary experiences of pediatric health care professionals' (HCPs) caring for hospitalized Medically Fragile Infants (MFI) and their parents.

DESIGN AND METHODS

Convenience sampling was adopted to recruit 26 HCPs who provided care to MFI and their parents on inpatient units at a large tertiary pediatric hospital in Western Canada. Participants participated in either a focus group or individual face-to-face interview. Themes and concepts emerged during open and focused coding.

FINDINGS

HCPs encountered barriers to establishing relationships with parents, including: (a) intricate nature of MFI, (b) lack of social supports, (c) inconsistency, (d) moral distress, (e) burnout, and (f) struggle to gain control. HCPs utilized strategies to establish relationships with parents, including: (a) normalizing and building parental confidence, (b) tailoring care and being flexible, (c) providing parent care, and (d) optimizing communication.

CONCLUSION

HCPs aimed to establish relationships built on trust with parents of MFI to empower and enable parents to care for their infants. The relationship was the vehicle to enhance the care provided and well-being of MFI. HCPs encountered barriers to establishing trusting relationships and utilized strategies to establish such relationships.

PRACTICE IMPLICATIONS

It is valuable to understand the importance that the parent-HCPs relationship plays in the care provided to hospitalized MFI and how lack thereof can lead to moral distress and burnout among HCPs. Increasing HCPs' awareness of barriers and strategies to the establishment of a trusting relationship with parents could help improve the collaborative relationship between parents and HCPs.

Pediatric Palliative Care in a Pandemic: Role Obligations, Moral Distress, and the Care You Can Give

Many ethical issues arise concerning the care of critically ill and dying patients during the coronavirus disease 2019 (COVID-19) pandemic. In this issue's Ethics Rounds, we present 2 cases that highlight 2 different sorts of ethical issues. One is focused on the decisions that have to be made when the surge of patients with respiratory failure overwhelm ICUs. The other is focused on the psychological issues that arise for parents who are caring for a dying child when infection-control policies limit the number of visitors. Both of these situations raise challenges for caregivers who are trying to be honest, to deal with their own moral distress, and to provide compassionate palliative care.

Moral distress: Developing strategies from experience

BACKGROUND

Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress.

OBJECTIVES

We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience.

RESEARCH DESIGN

An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers.

PARTICIPANTS

Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital.

RESEARCH CONTEXT

This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies.

ETHICAL CONSIDERATIONS

The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project.

FINDINGS

Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports.

DISCUSSION

Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting.

CONCLUSION

This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

Moral Distress of Clinicians in Canadian Pediatric and Neonatal ICUs

OBJECTIVE

To quantify moral distress in neonatal ICU and PICU clinicians and to identify associated factors.

DESIGN

A national cross-sectional survey of clinicians working in an neonatal ICU or PICU. Moral distress was assessed with the Moral Distress Scale-Revised and by self-rating. Depersonalization was assessed on the subscale of the Maslach Burnout Inventory. Respondents reported their attendance at each of six hospital supports that may serve to mitigate moral distress in frontline staff. Analyses compared outcomes across respondent characteristics and hierarchical linear regression evaluated individual, ICU, hospital, and regional effects.

SETTING

Eligible ICUs were PICUs and level-3 neonatal ICUs in Canada.

SUBJECTS

Eligible participants had worked in the participating ICU for more than 3 months.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 54 eligible ICUs from 31 hospitals. Forty-nine Canadian neonatal ICUs and PICUs (91%) contributed 2,852 complete responses for a 45.2% response rate. Most respondents were nurses (64.9%) or from a neonatal ICU (66.5%). The median and interquartile range Moral Distress Scale-Revised were 79 (52-113); 997 respondents (34.2%) had Moral Distress Scale-Revised scores greater than or equal to 100, and 234 respondents (8.3%) strongly agreed that work caused them significant moral distress. Nurses had a median (interquartile range) Moral Distress Scale-Revised score of 85 (57-121), 19 points higher than physicians and 8 points higher than respiratory therapists (p < 0.0001). Moral Distress Scale-Revised scores increased from 53 (35-79) for those working in ICU less than 1 year to 83 (54-120) in those working in ICU more than 30 years (p < 0.0001); 22.5% reported high degrees of depersonalization, which was associated with moral distress (p < 0.0001). Variability in Moral Distress Scale-Revised scores was explained by individual-level (92%), hospital-level (5%), and ICU-level effects (1%). Frequency of participation in potentially mitigating hospital supports had small effects (< 10 points) on mean Moral Distress Scale-Revised scores.

CONCLUSIONS

Moral distress is common in clinicians working in ICUs for children. Addressing moral distress will require interventions tailored to individuals in higher-risk groups.

Important situations that capture moral distress in paediatric oncology

BACKGROUND

The paediatric Moral Distress Scale-Revised (MDS-R) was previously translated and adapted to Swedish paediatric oncology. Cognitive interviews revealed five not captured situations among the 21 items, resulting in five added items: 22) Lack of time for conversations with patients/families, 23) Parents' unrealistic expectations, 24) Not to talk about death with a dying child, 25) To perform painful procedures, 26) To decide on treatment/care when uncertain. The aim was to explore experiences of moral distress in the five added situations in the Swedish paediatric MDS-R, among healthcare professionals (HCPs) in paediatric oncology.

METHODS

In this national cross-sectional survey, the Swedish paediatric MDS-R, including five added items, were used. Descriptive statistics, non-parametric analysis of differences between professions and a MDS-R score for each item were calculated. Internal consistency was tested using Cronbach's alpha and inter-item correlation test. HCPs (n = 278) at all six Swedish paediatric oncology centres participated (> 89%). The Regional Ethical Review Board had no objections. Consent was assumed when the survey was returned.

RESULTS

Nursing assistants (NAs) reported higher intensity and lower frequency on all added items; registered nurses (RNs) reported a higher frequency on item 22-25; medical doctors (MDs) reported higher MDS-R score on item 26. On item 22, intensity was moderate for RNs and MDs and high for NAs, and frequency was high among all. Item 22, had the second highest MDS-R score of all 26 for all professional groups. On item 23, the level of disturbance was low but it occurred often. The 26-item version showed good internal consistency for the overall sample and for all professional groups. However, item 22 and 24 could be viewed as redundant to two of the original 21.

CONCLUSION

In accordance with other studies, the intensity was higher than the frequency, however, the frequency of the added items was higher than of the original items. In line with previous research, item 22 and 23 are important elements of moral distress. RNs experience the situations more often while NAs find them more disturbing. The results indicate that the added items are important in capturing moral distress in paediatric oncology.

Moral Distress and Considering Leaving in NICU Nurses: Direct Effects and Indirect Effects Mediated by Burnout and the Hospital Ethical Climate

BACKGROUND

Moral distress in neonatal intensive care unit (NICU) nurses predicts burnout, the hospital ethical climate, and considering leaving the position. However, the direct effect of moral distress on considering leaving and the indirect effects mediated by burnout and the hospital ethical climate remain unexamined in these nurses.

OBJECTIVES

The aim of this study was to examine the direct effect of moral distress on considering leaving and the indirect effects mediated by burnout and the hospital ethical climate in NICU nurses.

METHODS

This is an observational, multicentre, self-report questionnaire study of NICU nurses currently providing direct newborn care on 6 Level 3-4 NICUs in New South Wales, Australia.

RESULTS

Of the estimated 585 eligible nurses, 136 (23%) participated in the study. Twenty-one percent of the nurses were considering leaving. After controlling for the other predictor variables, moral distress did not predict considering leaving (p = 0.651). Burnout (odds ratio [OR] 4.25, p < 0.001) and the hospital ethical climate (OR = 0.29, p = 0.020) were significant predictors of considering leaving. The direct effect of moral distress on considering leaving was not significant, but the indirect effects mediated by burnout (B = 0.32, 95% confidence interval [CI] [0.147-0.611]) and the hospital ethical climate (B = 0.19, 95% CI [0.085-0.382]) were significant.

CONCLUSIONS

The support of NICU nurses considering leaving should include preventing and resolving moral distress, managing burnout, and enriching the ethical climate of the hospital. This support may reduce psychological distress in NICU nurses and maintain or enhance the standard of care for sick newborns.

Moral distress experienced by non-Western nurses: An integrative review

BACKGROUND

Moral distress has been identified as a significant issue in nursing practice for many decades. However, most studies have involved American nurses or Western medicine settings. Cultural differences between Western and non-Western countries might influence the experience of moral distress. Therefore, the literature regarding moral distress experiences among non-Western nurses is in need of review.

AIM

The aim of this integrative review was to identify, describe, and synthesize previous primary studies on moral distress experienced by non-Western nurses.

REVIEW METHOD

Whittemore and Knafl's integrative review methodology was used to structure and conduct the review of the literature.

RESEARCH CONTEXT AND DATA SOURCES

Key relevant health databases included the Ovid MEDLINE, CINAHL, Web of Science, and Google Scholar databases. Two relevant journals, Nursing Ethics and Bioethics, were manually searched.

ETHICAL CONSIDERATION

We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources.

FINDINGS

A total of 17 primary studies published between 1999 and 2019 were appraised. There was an inconsistency with regard to moral distress levels and its relationship with demographic variables. The most commonly cited clinical causes of moral distress were providing futile care for end-of-life patients. Unit/team constraints (poor collaboration and communication, working with incompetent colleagues, witnessing practice errors, and professional hierarchy) and organizational constraints (limited resources, excessive administrative work, conflict within hospital policy, and perceived lack of support by administrators) were identified as moral distress's stimulators. Negative impacts on nurses' physical, psychological, and spiritual well-being were also reported.

CONCLUSION

Further research is needed to investigate moral distress among other healthcare professions which may further build understanding. More importantly, interventions to address moral distress need to be developed and tested.

Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals

BACKGROUND

As ongoing research explores the impact of moral distress on health care professionals (HCPs) and organizations and seeks to develop effective interventions, valid and reliable instruments to measure moral distress are needed. This article describes the development and testing of a revision of the widely used Moral Distress Scale-Revised (MDS-R) to measure moral distress.

METHODS

We revised the MDS-R by evaluating the combined data from 22 previous studies, assessing 301 write-in items and 209 root causes identified through moral distress consultation, and reviewing 14 recent publications from various professions in which root causes were described. The revised 27-item scale, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), is usable by all HCPs in adult and pediatric critical, acute, or long-term acute care settings. We then assessed the reliability of the MMD-HP and evaluated construct validity via hypothesis testing. The MMD-HP, Hospital Ethical Climate Survey (HECS), and a demographic survey were distributed electronically via Qualtrics to nurses, physicians, and other health care professionals at two academic medical centers over a 3-week period.

RESULTS

In total, 653 surveys were included in the final analysis. The MMD-HP demonstrated good reliability. The four hypotheses were supported: (1) MMD-HP scores were higher for nurses (M 112.3, SD 73.2) than for physicians (M 96.3, SD 54.7, p = 0.023). (2) MMD-HP scores were higher for those considering leaving their position (M 168.4, SD 75.8) than for those not considering leaving (M 94.3, SD 61.2, p < 0.001). (3) The MMD-HP was negatively correlated with the HECS (r = -0.55, p < 0.001). (4) An exploratory factor analysis revealed a four-factor structure, reflective of patient, unit, and system levels of moral distress.

CONCLUSIONS

The MMD-HP represents the most currently understood causes of moral distress. Because the instrument behaves as would be predicted, we recommend that the MMD-HP replace the MDS-R.

Moral Distress in the Pediatric Intensive Care Unit: An Italian Study

Introduction: There is paucity of data within the Italian context regarding moral distress in intensive pediatric settings. The aim of the present study was to assess the frequency, intensity, and level of moral distress experienced by nurses working in a sample of pediatric intensive care units (PICUs). Materials and Methods: A cross-sectional questionnaire survey was conducted in eight PICUs from five northern Italian regions in a convenience sample of 136 nurses. Moral distress was evaluated using the modified Italian version of the Moral Distress Scale Neonatal-Pediatric Version (MDSNPV). Each item was scored in terms of frequency and intensity on a five-point Likert scale, ranging from 0 to 4. The total frequency and intensity scores for all the 21 clinical items were comprised between 0 and 84. For each item, the level of moral distress was derived by multiplying the frequency score by the intensity score and quantified with a score ranging from 0 to 16. The total score of the moral distress level for the 21 items ranged from 0 to 336. Results: The mean total scores for the frequency, intensity and level of moral distress were 24.1 ± 10.4, 36.2 ± 18.6, and 57.7 ± 37.1, respectively. The clinical situations identified as the major causes of moral distress among nurses in the present study involved end-of-life care and resuscitation. At multivariate logistic regression analysis, number of deaths occurring in PICUs, having children and intention to leave work due to moral distress resulted to be independently associated with a higher total moral distress level. Conclusions: The results of the present study contribute to the understanding of moral distress experience in acute pediatric care settings, including the clinical situations associated with a higher moral distress level, and highlight the importance of sharing thoughts, feelings and information within the multidisciplinary health care professional team for effective shared decision making, particularly in situations involving end-of-life care and resuscitation.

Nurses' Moral Distress, Burnout, and Intentions to Leave: An Integrative Review

Moral distress has been widely addressed across the nursing profession and within other disciplines. Forensic nurses are a vital part of the nursing profession as they care for complex patients who may suffer physically and psychologically. However, forensic nurses' moral distress in the context of caring for victims of violence has not been addressed. This integrative review of the literature reveals the consequences of moral distress on the nursing workforce particularly regarding nurses' burnout and intentions to leave their jobs. Turnover contributes to the country's critical shortage of nurses, which affects the quality of care patients receive and increases the costs for healthcare institutions.

Moral distress in paediatric oncology: Contributing factors and group differences

BACKGROUND

Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress.

OBJECTIVES

To explore healthcare professionals' experiences of situations that generate moral distress in Swedish paediatric oncology.

RESEARCH DESIGN

In this national study, data collection was conducted using the Swedish Moral Distress Scale-Revised. The data analysis included descriptive statistics and non-parametric analysis of differences between groups.

PARTICIPANTS AND RESEARCH CONTEXT

Healthcare professionals at all paediatric oncology centres in Sweden were invited to participate. A total of 278 healthcare professionals participated. The response rate was 89%.

ETHICAL CONSIDERATIONS

In its advisory statement, the Regional Ethical Review Board decided that the study was of such a nature that the legislation concerning ethical reviews was not applicable. All participants received written information about the aim of the study and confidentiality. Participants demonstrated their consent by returning the survey.

FINDINGS

The two situations with the highest moral distress scores concerned lack of competence and continuity of personnel. All professional groups reported high levels of disturbance. Nurses rated significantly higher frequencies and higher total Moral Distress Scale scores compared to medical doctors and nursing assistants.

DISCUSSION

Lack of competence and continuity, as the two most morally distressing situations, confirms the findings of studies from other countries, where inadequate staffing was reported as being among the top five morally distressing situations. The levels of total Moral Distress Scale scores were more similar to those reported in intensive care units than in other paediatric care settings.

CONCLUSION

The two most morally distressing situations, lack of competence and continuity, are both organisational in nature. Thus, clinical ethics support services need to be combined with organisational improvements in order to reduce moral distress, thereby maintaining job satisfaction, preventing a high turnover of staff and ensuring the quality of care.