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Miranda ACR, Fernandes SD, Ramos S, Nunes E, Fabri J, Caldeira S. Moral Distress of Nurses Working in Paediatric Healthcare Settings. Healthcare (Basel) 2024; 12:1364. [PMID: 38998898 DOI: 10.3390/healthcare12131364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
This scoping review aims to map the evidence on moral distress of nurses working in paediatric healthcare settings from homecare to hospital. It was conducted according to the Joanna Briggs Institute. International databases were searched according to the specific thesaurus and free search terms. Independent screening and analysis were conducted using Rayyan QCRI. This review considered a total of 54 studies, including quantitative and qualitative studies, systematic reviews, and grey literature; English and Portuguese languages were included. Moral distress is a phenomenon discussed in nursing literature and in the paediatric context but is considered absent from discussion in clinical practice. It is caused by disproportionate care associated with overtreatment. Nurses can present a variety of symptoms, characterising moral distress as a highly subjective experience. The paediatric contexts of practice should promote a healthy ethical climate and work towards a moral community built with peer support, education, communication, leadership, and management involvement. Moral distress is still a complex and challenging multidimensional concept, and the aim should be to promote a culture of prevention of the devastating consequences of moral distress and work towards moral resilience.
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Affiliation(s)
| | | | - Sílvia Ramos
- Nursing School Lisbon, Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal
| | - Elisabete Nunes
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, 1600-190 Lisbon, Portugal
| | - Janaína Fabri
- Faculty of Nursing, Universidade Estadual do Rio de Janeiro, Rio de Janeiro 20551-030, Brazil
| | - Sílvia Caldeira
- Center for Interdisciplinary Research in Health, Faculty of Health Sciences and Nursing, Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal
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Alexander D, Quirke MB, Berry J, Eustace-Cook J, Leroy P, Masterson K, Healy M, Brenner M. Initiating technology dependence to sustain a child's life: a systematic review of reasons. JOURNAL OF MEDICAL ETHICS 2022; 48:1068-1075. [PMID: 34282042 PMCID: PMC9726963 DOI: 10.1136/medethics-2020-107099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions. METHODS Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence. RESULTS 53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care. CONCLUSIONS There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mary Brigid Quirke
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jay Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | | | - Piet Leroy
- Pediatric Intensive Care Unit & Pediatric Procedural Sedation Unit, Maastricht UMC+, Maastricht, The Netherlands
| | - Kate Masterson
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care, Our Lady's Hospital Crumlin, Crumlin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Alexander D, Eustace-Cook J, Brenner M. Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time. J Child Health Care 2021; 25:509-522. [PMID: 32966106 DOI: 10.1177/1367493520961884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
| | | | - Maria Brenner
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
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Sannino P, Giannì ML, Carini M, Madeo M, Lusignani M, Bezze E, Marchisio P, Mosca F. Moral Distress in the Pediatric Intensive Care Unit: An Italian Study. Front Pediatr 2019; 7:338. [PMID: 31456996 PMCID: PMC6700377 DOI: 10.3389/fped.2019.00338] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Patrizio Sannino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Direzione Professioni Sanitarie, Milan, Italy
| | - Maria Lorella Giannì
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Micaela Carini
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Madeo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Direzione Professioni Sanitarie, Milan, Italy
| | - Maura Lusignani
- ASST Grande Ospedale Metropolitano Niguarda, Bachelor of Nursing, Course Session, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Elena Bezze
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Marchisio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Wocial L, Ackerman V, Leland B, Benneyworth B, Patel V, Tong Y, Nitu M. Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU. HEC Forum 2017; 29:75-91. [PMID: 27815753 DOI: 10.1007/s10730-016-9313-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer (MDT) scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised (MDS-R), were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p = 0.015), a statistically significant increase in both code status changes DNR (11 % control, 28 % PEACE, p = 0.013), and in-hospital death (9 % control, 25 % PEACE, p = 0.015), with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients.
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Affiliation(s)
- Lucia Wocial
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.
- Indiana University School of Nursing, Indianapolis, IN, USA.
| | - Veda Ackerman
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Brian Leland
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Brian Benneyworth
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
- Children's Health Services Research Unit, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vinit Patel
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Yan Tong
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Mara Nitu
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
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