Moral distress in the neonatal intensive care unit: an Italian study

Factors contributing to moral distress among intensive care nurses: A scoping review

Background: The intensive care unit (ICU) is a busy and complex workplace, and several work-related and personal factors are known to make ICU nurses more vulnerable to moral distress than other healthcare professionals. It is crucial to identify these factors to guide future studies and preventive strategies. This scoping review explores such factors to present current knowledge on the factors that trigger moral distress and to guide future research by reviewing studies to explore and summarize factors that trigger moral distress in ICU nurses. Methods: The PubMed, EBSCO, and CINAHL Plus databases were searched to identify potentially relevant studies published between 2011 to 2022. Inclusion criteria: peer-reviewed studies published in English that provided results regarding factors causes or correlated to moral distress in ICU nurses. After removing 618 duplicates, 316 papers were excluded after title and abstract screening, leaving 71 articles for full-text screening. A further 54 articles were excluded as their outcomes did not include factors that caused moral distress, or were not specific to ICU nurses, so 17 studies were eventually analysed using qualitative content analysis through an inductive approach. The findings of the articles were extracted and coded independently by two authors, and data were grouped and categorized. Results: The content categories of factors contributing to ICU nurses' moral distress were organized into themes and subthemes. Four major themes were identified: Powerlessness, end-of-life care, ineffective teamwork, and personal characteristics of ICU nurses. Conclusions: This review highlights the factors that contribute to moral distress in critical care nurses, which are mainly attributable to the organizational climate and the nature of the ICU clinical environment. Descriptive and intervention studies (experimental or action research) must investigate causality between identified variables to inform management strategies to improve support for ICU nurses' coping relative to moral distress.

Webcam technology on neonatal wards-examining the objective and subjective workload of nurses: a combined observational and survey study

BACKGROUND

This study was conducted to estimate the additional objective and perceived workload of nurses resulting from the use of webcams. The successful implementation of webcam technology into routine care requires an analysis to prevent adverse events of increased nursing workload.

METHODS

The study took place on three neonatal wards in two University Hospitals in Germany. In the first Hospital, the study was conducted from February to July 2021; in the second one it was conducted between June and November 2021. Data were collected using a combined approach of a standardised diary questionnaire study and passive observations. The participants were accompanied in their daily work and their activities were recorded 65 nurses participated.

RESULTS

2,031 h were observed in 1,630 observation blocks. In 14.74% of the observation blocks webcam activities were detected. The extent to which the nurses had webcam-related additional workloads was rated as no additional workload in 82.16% of the daily questionnaires (n = 1,026).

CONCLUSION

The observed low workload due to the webcams is in line with the nurses' perception. The observational data revealed, on a number of different analysis levels, that a limited additional workload was generated. There was no decrease in activity performance observed and no clear indication for interruptions due to the webcam-related activities for the nurses. However, it is important to raise awareness about the individual workload levels for the successful implementation. Additional education programs can be provided for nurses.

TRIAL REGISTRATION

The Neo-CamCare study is registered at the German Clinical Trials Register.

DRKS-ID

DRKS00017755 .

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.

The Impact of Loving-Kindness Meditation on Compassion Fatigue of Nurses Working in the Neonatal Intensive Care Unit: A Randomized Clinical Trial Study

Compassion fatigue is a common complication in nurses, which can lead to burnout, job dissatisfaction, and a decline in the quality of patient care. This study aimed to investigate the impact of loving-kindness meditation on compassion fatigue of nurses working in the neonatal intensive care unit (NICU). This cluster-blinded randomized clinical trial study was conducted on 66 NICU nurses in 2 educational hospitals selected. The intervention group received a 1-month online program for daily training and practice of loving-kindness meditation. The control group received miscellaneous files on mental health during the COVID-19 pandemic period. The Nursing Compassion Fatigue Inventory (NCFI) was filled out by the 2 groups, before and after the intervention. The results showed that the mean scores of the NCFI in the intervention group decreased significantly compared with before the intervention (P = .002). In comparison with the control group, there was a significant difference between the mean scores of the 2 groups after the intervention (P = .034). Among nurses working in NICU, loving-kindness meditation significantly reduces compassion fatigue after 1 month. These findings support the use of this intervention for nurses.

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.

Moral Distress and Burnout in NICU Nurses

The objectives of this study were to factor analyze the Moral Distress Scale-Revised (MDS-R) in NICU nurses and to evaluate the relationships among dimensions of the MDS-R and the demoralization, exhaustion, and loss of motive dimensions of the Burnout Measure (BM). A total of 142 NICU nurses completed modified pen-and-paper versions of the MDS-R and BM. Exploratory and confirmatory factor analyses showed that the MDS-R-14 was a relatively good fit for the data. The compromised care dimension predicted BM demoralization (β = 0.24) and exhaustion (β = 0.22), the futile care dimension predicted BM exhaustion (β = 0.18), and the untruthful care dimension predicted BM demoralization (β = .25). Strategies to mitigate moral distress and resulting burnout in NICU nurses should address futile care, compromised care, and untruthful care.

Impact of Dying Neonates on Doctors' and Nurses' Personhood: A Systematic Scoping Review

CONTEXT

Caring for dying neonates is distressing for healthcare professionals (HCP)s. Yet, the extent of these effects is poorly understood, compromising support of HCPs. To better understand and support HCPs, a systematic scoping review (SSR) of prevailing data is proposed.

OBJECTIVES

In mapping prevailing data on the impact of caring for dying neonates on HCPs, an SSR proffers new insights on changes to their beliefs, values, coping, actions, relationships and self-concepts of personhood.

METHODS

Krishna's Systematic Evidenced Based Approach (SEBA) supports a robust, reproducible review whilst its constructivist approach and relativist lens effectively contends with diverse data sources, facilitating a holistic study.

RESULTS

A total of 9826 abstracts were reviewed and 69 articles were included. Thematic and content analysis were used simultanously. The four categories drawn from the Ring Theory of Personhood (RToP) complements the four themes identified: Emotional and Physical Difficulties, Coping Mechanisms, Conflict and Recommendations.

CONCLUSION

In highlighting significant longitudinal effects upon all aspects of their lives, this SSR in SEBA reveals a critical need for timely, appropriate and personalized support. We recommend adapting the RToP as an assessment tool to identify and evaluate the needs of these HCPs. It may also be used to structure a holistic support mechanism. Future studies are required to validate its use and appraise other aspects of support available for HCPs.

Psychosocial and psychological interventions' effectiveness among nurses in intensive care units caring for pediatric patients: A systematic review and meta-analysis

OBJECTIVE

This review aimed to evaluate the effectiveness of psychosocial and psychological interventions in nurses among intensive care units caring for pediatric patients.

METHODS

A literature search was performed in PubMed, EMBASE, CINAHL databases, using preferred reporting items for systematic reviews and meta-analysis guidelines. Study design, population characteristics, contents of the programs, measured outcomes, and results were systematically reviewed from 8 selected studies. To estimate the effect size, a meta-analysis of the studies was performed using the RevMan 5.3 program. The effect size used was the standardized mean difference.

RESULTS

Of 1,630 studies identified, 4 met the inclusion criteria, and 3 studies were used to estimate the effect size of psychosocial and psychological interventions. The primary outcome variable of these studies was stress. The effect of the intervention program on stress was also found to have no effect in individual studies, and the overall effect size was not statistically significant (standardized mean difference = -0.06; 95% confidence interval: -0.33, 0.20; Z = 0.48, p = 0.630). However, according to the individual literature included in this study, after the stress management program was applied as a group, a significant stress reduction was shown in the experimental group (p = 0.021).

CONCLUSIONS

These results show that psychosocial and psychological interventions were effective in stress management by a group approach. Therefore, it is necessary to develop psychosocial support interventions for stress management of nurses among intensive care units caring for pediatric patients more diversely.

Relationship Between Moral Distress and Intent to Leave a Position Among Neonatal Intensive Care Nurses

BACKGROUND

The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses.

PURPOSE

To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey.

METHODS

A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020.

FINDINGS

A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress.

IMPLICATIONS

for Practice: NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses.

IMPLICATIONS FOR RESEARCH

Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.

Self-Report and Biological Indexes of Work-Related Stress in Neonatal Healthcare Professionals: A Repeated-Measures Observational Study

BACKGROUND

Healthcare providers working in neonatal intensive care units (NICUs) are considered at high risk for psychological work-related stress.

PURPOSE

To evaluate both perceived and biological measures of work-related stress in neonatal healthcare professionals and to compare professionals working in the NICU with their colleagues working in less critical environments (ie, neonatal wards [NWs]).

METHODS

The salivary cortisol level at the beginning (CORT-B) and at the end (CORT-E) of a daily work shift was collected once a week for 6 weeks and a psychological questionnaire was submitted to NW and NICU workers of a tertiary university center.

RESULTS

No differences emerged in the overall cortisol secretion between professionals (NW 45 vs NICU 28), but the decrease in the mean cortisol values between CORT-B and CORT-E was less pronounced in NICU professionals (P < .001) who had greater psychological stress (P < .001). Lack of correlation between perceived and biological indexes was observed.

IMPLICATIONS FOR PRACTICE

NICU professionals reported greater levels of self-perceived psychological stress, especially in terms of professional self-doubt and the complexity of interactions with infants and their parents.The disconnection between psychological and biological indexes raises the issue that work-related stress might be covert to the professionals themselves. Dedicated resources should be developed to address quality of life and the work environment of NICU professionals.

IMPLICATIONS FOR RESEARCH

The absence of a correlation between perceived and biological indexes highlights the need to incorporate multidimensional physiological and biological measurements in evaluating burnout levels in neonatal healthcare providers.

Psychometrics of the moral distress scale in Iranian mental health nurses

BACKGROUND

One of the challenges that nurses often face in ethical decision-making situations is moral distress. Moral distress is caused by the conflict between professional and individual values in decision-making situations. Despite its importance, there is no reliable scale in Persian to measure it. Therefore, this study was conducted to validate the moral distress scale in mental health nurses in Iranian culture and Persian language.

METHODS

This study was conducted in two parts: Translation and cross-cultural adaptation and psychometric analysis. The translation and cross-cultural adaptation process was conducted based on the Polit approach. Next, face validity (qualitative), content validity (quantitative and qualitative), and construct validity were examined. This part of the study was a cross-sectional study. In this step, a demographic questionnaire and the Moral Distress Scale were sent to 500 nurses working in selected educational and medical centers in Iran via online questionnaires. Then, the construct validity of the "Moral Distress Scale" was confirmed by confirmatory factor analysis and the reliability of the instrument was examined by studying the internal consistency with Cronbach's alpha and the internal correlation of the AIC.

RESULTS

The confirmatory factor analysis showed an acceptable ratio of the expressions in 15 items in three factors: Acquiescence to patients' rights violations (6 items), Unethical conduct by caregivers (5 items), and low staffing (4 items) in the scale. The internal consistency of the instrument with Cronbach's alpha was higher than 7.0.

CONCLUSION

The Persian version of moral distress with 15 items of the three factors had validity and reliability. According to the present findings, this scale can be used to study moral distress among nurses working in psychiatric wards. Moral distress leads to burnout, increases risks to patient safety and reduces quality of care. Nurses need to be able to assess and manage moral distress. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. Considering that culture has an impact on nurses' moral distress, it is suggested that this instrument be studied in and tested in other languages and cultures.

End-of-Life Care Related Distress in the PICU and NICU: A Cross-Sectional Survey in a German Tertiary Center

Objective: To investigate and compare nurses' perceived care-related distress and experiences in end-of-life situations in neonatal and pediatric intensive care units. Study design: Single-center, cross-sectional survey. Administration of an anonymous self-report questionnaire survey to nurses of two tertiary neonatal intensive care units (NICUs), and two tertiary pediatric intensive care units (PICUs) in Berlin, Germany. Results: Seventy-three (73/227, response rate 32.2%) nurses completed surveys. Both, NICU (32/49; 65.3%) and PICU (24/24; 100.0%) nurses, reported "staffing shortages" to be the most frequent source of distress in end-of-life situations. However, when asked for the most distressing factor, the most common response by NICU nurses (17/49) was "lack of clearly defined and agreed upon therapeutic goals", while for PICU nurses (12/24) it was "insufficient time and staffing". No significant differences were found in reported distress-related symptoms in NICU and PICU nurses. The interventions rated by NICU nurses as most helpful for coping were: "discussion time before the patient's death" (89.6%), "team support" (87.5%), and "discussion time after the patient's death" (87.5%). PICU nurses identified "compassion" (98.8%), "team support", "personal/private life (family, friends, hobbies)", and "discussion time after the patient's death" (all 87.5%) as most helpful. Conclusions: Distress-related symptoms as a result of end-of-life care were commonly reported by NICU and PICU nurses. The most frequent and distressing factors in end-of-life situations might be reduced by improving institutional/organizational factors. Addressing the consequences of redirection of care, however, seems to be a more relevant issue for the relief of distress associated with end-of-life situations in NICU, as compared to PICU nurses.

Emotional Intelligence in Neonatal Intensive Care Unit Nurses: Decreasing Moral Distress in End-of-Life Care and Laying a Foundation for Improved Outcomes: An Integrative Review

End-of-life care in the neonatal intensive care unit (NICU) is one of the most challenging practices for nurses. Negative emotions associated with moral distress often cause care to be incomplete or nurse disengagement. Emotional intelligence in nurses holds potential to address this issue, while improving patient outcomes. The purpose of this study was to critically appraise the evidence about emotional intelligence in nursing and to explore the relationship between emotional intelligence, moral distress in NICU nurses, end-of-life care, and other priority nurse and patient outcomes. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-structured integrative review was conducted, and CINAHL, Ovid, PubMed, and other databases were searched. Twelve studies were identified as relevant to this review after exclusion criteria were applied. Evidence supports the efficacy of emotional intelligence in bedside nurses as a method of improving key nurse and patient outcomes. Additionally, research suggests that emotional intelligence can be improved by training interventions. Clinical educators should integrate emotional intelligence concepts and strategies into staff training. Further research is recommended to validate previous findings in the NICU setting. Exploration of the relationship between emotional intelligence and moral distress in NICU nurses would provide a foundation for experimental designs to evaluate the effectiveness of emotional intelligence training interventions.

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 of nurses surrounding neonatal abstinence syndrome: Application of a theoretical framework

TOPIC

Neonatal nurses who care for infants with symptoms of neonatal abstinence syndrome (NAS) may experience moral distress through conflicting professional ethics. The nurse may find it difficult to simultaneously exemplify beneficence and nonmaleficence.

OBJECTIVE

The purpose of this paper is to explore the moral distress of nurses in the context of infants experiencing symptoms of NAS and apply a new conceptual model to this phenomenon. Understanding how nurses navigate moral dilemmas may provide insight into strategies to better support them to address moral conflict.

METHODS

Moral distress was explored in the context of nurses who care for infants with symptoms of NAS. A literature review was completed, followed by the application of the model onto the derived themes.

RESULTS

The theoretical application resulted in a framework that exemplifies the experience of caring for infants with symptoms of NAS and their families described by many nurses within the literature. If moral distress is not resolved, negative outcomes may be experienced by the nurse, with additional negative outcomes experienced by the family.

CONCLUSION

This theoretical model provided insight into the experience of moral distress surrounding nursing care for infants with symptoms of NAS. Additional research is needed to investigate moral residue and moral resilience in this particular caregiving dynamic.

Does It Matter if This Baby Is 22 or 23 Weeks?

A 530-g girl born at 22 weeks and 6 days' gestation (determined by an ultrasound at 11 weeks) was admitted to the NICU. Her mother had received prenatal steroids. At 12 hours of age, she was stable on low ventilator settings. Her blood pressure was fine. Her urine output was good. After counseling, her parents voiced understanding of the risks and wanted all available life-supporting measures. Many nurses were distressed that doctors were trying to save a "22-weeker." In the past, 4 infants born at 22 weeks' gestation had been admitted to that NICU, and all had died. The attending physician on call had to deal with many sick infants and the nurses' moral distress.

Moral distress in correctional nurses: A national survey

Background:

Moral distress is an increasingly documented problem in nursing and might foster nurses’ intention to leave their workplace. It has been studied in different settings, but no specific research has been conducted in Italian correctional facilities. A recent Italian study produced a preliminary validation of the Moral Distress Scale for Correctional Nurses, which needs to be completed.

Objectives:

To investigate the level of moral distress of nurses working in the Italian correctional setting, by completing the validation process of the Moral Distress Scale for Correctional Nurses.

Methodology:

Multicenter questionnaire survey. All correctional nurses (461) affiliated with the Italian Society of Medicine and Penitentiary Health (also called “Simspe-onlus”) were invited to participate and 238 responded. The survey was conducted between April and November 2017 through SurveyMonkey®. Analysis of covariance was conducted to investigate the relationship between moral distress and the other variables under study. Exploratory factor analysis was conducted on the scale to confirm its dimensions.

Ethical considerations:

The study was approved by the Italian Society of Medicine and Penitentiary Health (Simspe-onlus). The questionnaire included informed consent, pursuant to the law in force. The software could not accept questionnaires without explicit consent. Data were analyzed anonymously.

Findings:

The median score was 46.5, indicating moderate moral distress. The only variable affecting moral distress was work experience in correctional facilities. Longer experience was correlated to higher levels of moral distress and intention to leave. Incompetent colleagues and short staffing were related to higher levels of moral distress. The scale confirmed the one-dimensional structure suggested by the original authors.

Discussion:

This is the first study investigating moral distress among Correctional Nurses. The prison context is a high-risk environment for nurses, increasing the intention to leave the workplace.

Conclusion:

Corrective and protective measures, such as specific education, are needed to prevent moral distress development and to reduce nurses’ shortage in this area.

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.

Applying a Balm: Medicating the Patient to Treat the (Moral) Distress of Caregivers

Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.

Always a burden? Healthcare providers' perspectives on moral distress

BACKGROUND

Current conceptualisations of moral distress largely portray a negative phenomenon that leads to burnout, reduced job satisfaction and poor patient care.

OBJECTIVE

To explore clinical experiences, perspectives and perceptions of moral distress in neonatology.

DESIGN

An anonymous questionnaire was distributed to medical and nursing providers within two tertiary level neonatal intensive care units (NICUs)-one surgical and one perinatal-seeking their understanding of the term and their experience of it. Open-ended questions were analysed using qualitative methodology.

RESULTS

A total of 345 healthcare providers from two NICUs participated (80% response rate): 286 nurses and 59 medical providers. Moral distress was correctly identified as constrained moral judgement resulting in distress by 93% of participants. However, in practice the term moral distress was also used as an umbrella term to articulate different forms of distress. Moral distress was experienced by 72% of providers at least once a month. Yet despite the negative sequelae of moral distress, few (8% medical, 21% nursing providers) thought that moral distress should be eliminated from the NICU. Open-ended responses revealed that while interventions were desired to decrease the negative impacts of moral distress, moral distress was also viewed as an essential component of the caring profession that prompts robust discussion and acts as an impetus for medical decision-making.

CONCLUSIONS

Moral distress remains prevalent within NICUs. While the harmful aspects of moral distress need to be mitigated, moral distress may have a positive role in advocating for and promoting the interests of the neonatal population.

Mental Health Symptoms and Work-Related Stressors in Hospital Midwives and NICU Nurses: A Mixed Methods Study

Hospital midwives and neonatal intensive care (NICU) nurses frequently encounter work-related stressors and are therefore vulnerable to developing mental health problems, such as secondary traumatic stress, burnout, anxiety, and depression. However, so far, the exact nature of these work-related stressors (traumatic vs. non-traumatic stressors) has not been investigated. This concurrent triangulation mixed methods cross-sectional study aimed to compare mental health symptoms in hospital midwives and NICU nurses, and to identify and compare work-related traumatic and non-traumatic stressors for both professional groups. 122 midwives and 91 NICU nurses of two Swiss university hospitals completed quantitative measures (Secondary Traumatic Stress Scale, STSS; Hospital Anxiety and Depression Scale, HADS; Maslach Burnout Inventory, MBI) and one qualitative question in an online survey. When controlling for socio-demographic variables, NICU nurses had a higher STSS total score and higher STSS subscales scores and less HADS anxiety subscale scores than hospital midwives. Work-related stressors were classified into five themes: "Working environment," "Nursing/midwifery care," "Dealing with death and dying," "Case management" and "Others." Forty-six (46.3%) percent of these were classified as traumatic work-related stressors. NICU nurses reported more traumatic stressors in their working environment but no other differences between professional groups regarding the total number of work-related traumatic vs. non-traumatic stressors were found. Measures, such as teaching strategies to amend the subjective appraisal of the traumatic stressors or providing time to recover in-between frequently occurring work-related traumatic stressors might not only improve the mental health of professionals but also decrease sick leave and improve the quality of patient care.

[Bioethics in end-of-life decisions in neonatology: Unresolved issues]

This document is the result of previous work carried out by different expert groups and submitted to multidisciplinary debate at a Conference about controversial, deficient, or new aspects in the field of neonatal palliative care, such as: 1) the deliberative decision-making process, 2) hospital and domiciliary palliative care, 3) donation after controlled cardiac death, and 4) moral stress in professionals. The most relevant conclusions were: the need to instruct professionals in bioethics and in the deliberative method to facilitate thorough and reasonable decision-making; the lack of development in the field of perinatal palliative care and domiciliary palliative care in hospitals that attend newborns; the need to provide neonatal units with resources that help train professionals in communication skills and in the management of moral distress, as well as delineate operational procedure and guidelines for neonatal organ donation.

Moral distress among nurses in medical, surgical and intensive-care units

AIM

To assess the frequency, intensity and level of moral distress perceived by nurses working in medical, surgical and intensive care units.

BACKGROUND

Moral distress among nurses compromises their ability to provide optimal patient care and may cause them to leave their job.

METHODS

A cross-sectional questionnaire survey of 283 registered nurses was conducted to evaluate the frequency, intensity and levels of moral distress. A revised version of the Moral Distress Scale (MDS-R) was used.

RESULTS

The highest level of moral distress was associated with the provision of treatments and aggressive care that were not expected to benefit the patients and the competency of the health-care providers. Multivariate regression showed that nurses working in medical settings, nurses with lower levels of experience working in medical, surgical or intensive care settings, and nurses who intend to leave their job experienced the highest levels of moral distress.

CONCLUSIONS

The present study indicates that nurses experience an overall moderate level of moral distress.

IMPLICATIONS FOR NURSING MANAGEMENT

Gaining further insight into the issue of moral distress among nurses and the clinical situations that most frequently cause this distress will enable development of strategies to reduce moral distress and to improve nurse satisfaction and, consequently, patient care.

Moral distress within neonatal and paediatric intensive care units: a systematic review

OBJECTIVE

To review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).

DESIGN

Pubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care.

RESULTS

13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly 'burdensome' and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating 'aggressive care'. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations.

CONCLUSIONS

Moral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.

Variabilities in the mortality-related resource utilisation for congenital heart disease

Objective

Our objective was to characterise the divergence of effort from outcome in congenital heart disease (CHD) care by measuring mortality-related resource utilisation fraction (MRRUF) for various CHD lesions across institutions of differing volumes.

Methods

Study design was observational analysis of an administrative database, the Pediatric Health Information System (PHIS). The setting was inpatient; 2004–2013. Patients were ≤21 years old with atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), hypoplastic left heart syndrome (HLHS) or other single ventricle (SV). There were no interventions but diagnosis, institution (and volume), age, length of hospitalisation, billed charges and deaths were recorded. The main outcome measure was MRRUF, the ratio of investments during hospitalisations ending in fatality to investments during all hospitalisations.

Results

There were 50 939 admissions, 1711 deaths, 703 383 inpatient days, and $10 182 000 000 billed charges. MRRUF varied widely by diagnosis: highest in HLHS (21%), but present in ASD (2%) and VSD (4%). Highest among the very young, MRRUF also increased in HLHS and SV during adolescence. MRRUF increased with hospitalisation duration. MRRUF had no relation to institutional volume, and was static over the decade studied.

Conclusions

Even in the modern era we invest heavily in inpatient CHD care that does not produce the desired outcome. Although its magnitude varies by lesion and age, MRRUF is not limited to complex disease in the very young. MRRUF is not decreasing, and is not isolated to high or low volume institutions.