Is This My Home? A Palliative Care Journey Through Life and Death in the NICU: A Case Report

Moral Distress and Its Relating Factors Among Pediatric Emergency Department Nurses: A Cross-Sectional Study

OBJECTIVES

Emergency services are patient circulation units that require chaos, trauma, and high tension. It was aimed to determine the moral distress levels of pediatric nurses in pediatric emergency and emergency departments and relevant factors.

METHODS

This study is a descriptive and cross-sectional study. It consists of 255 nurses with their data. The Participant Information Form and the Moral Distress Scale-Revised for Pediatric Nurses (MDS-R) were used to collect data.

RESULTS

In the study, the mean score of MDS-R frequency was found to be 27.36 ± 13.16, the mean score of MDS-R intensity to be 37.65 ± 17.53, and the mean total score of MDS-R to be 58.96 ± 39.40. It was determined that 93.7% of the nurses received training on moral distress, and education level was effective on moral distress levels of the nurses. The nurses working in the pediatric emergency service had higher moral distress levels than the nurses serving pediatric patients in the emergency department ( P(total MDS-R) = 0.02, P(frequency of MDS-R) = 0.008). Job satisfaction ( P(total MDS-R) = 0.003, P(frequency of MDS-R) < 0.001, P(intensity of MDS-R) < 0.001) and frequency of thinking about changing working unit ( P(frequency of MDS-R) = 0.02, P(intensity of MDS-R) = 0.01) were found to be effective on the level of moral distress. It was determined that the type of emergency service, the working time in the emergency service, and the level of job satisfaction significantly affected the total moral distress scores of the nurses ( P < 0.001, R2 = 0.09).

CONCLUSIONS

It was found in the study that nurses had low levels of moral distress; however, many factors relevant to working conditions were associated with moral distress. The pediatric emergency service nurses were determined to experience a higher moral distress compared with the emergency department nurses serving pediatric patients.

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.