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Beadle ES, Walecka A, Sangam AV, Moorhouse J, Winter M, Munro Wild H, Trivedi D, Casarin A. Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies. PLoS One 2024; 19:e0303013. [PMID: 38935754 PMCID: PMC11210881 DOI: 10.1371/journal.pone.0303013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 04/17/2024] [Indexed: 06/29/2024] Open
Abstract
OBJECTIVE At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions. METHODS A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic. RESULTS Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change. CONCLUSION This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.
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Affiliation(s)
- Emily S. Beadle
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | | | - Amy V. Sangam
- Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | | | - Matthew Winter
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Helen Munro Wild
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Daksha Trivedi
- Centre for Research in Public Health and Community Care, School of Health and Social Work, The University of Hertfordshire, Hatfield, United Kingdom
| | - Annalisa Casarin
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Broden EG, Eche-Ugwu IJ, DeCourcey DD, Wolfe J, Hinds PS, Snaman J. "At Least I Can Push this Morphine": PICU Nurses' Approaches to Suffering Among Dying Children. J Pain Symptom Manage 2024:S0885-3924(24)00738-3. [PMID: 38679304 DOI: 10.1016/j.jpainsymman.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
CONTEXT Parents of children who die in the pediatric intensive care unit (PICU) carry memories of their child's suffering throughout a lifelong grieving experience. Given their prolonged time at the bedside, PICU nurses are poised to attend to dying children's suffering. OBJECTIVES We aimed to explore how PICU nurses identify, assess, and attend to EOL suffering. METHODS Interpretive descriptive qualitative study with thematic analysis of virtual focus groups from a geographically diverse sample of PICU nurses. RESULTS Nurses participated in five focus groups (N = 19). Most identified as White (89%) females (95%) with a range of 1-24 years of PICU experience and involvement in >10 EOL care cases (89%). Nurses described approaches to suffering within five themes: 1) Identifying and easing perceptible elements; 2) Recognizing and responding to subtleties moment-to-moment; 3) Acclimating to family interdependence; 4) Synchronizing nurse in-the-room insight with systemic complexity; and 5) Accounting for ambiguity. Nurses detailed elements of suffering they could "fix" with straightforward, external interventions (e.g., pain medication). More complex tasks like optimizing care within familial and interprofessional team relationships while navigating psychosocial responses from children and families challenged nurses. Nurses attempted to minimize EOL suffering amidst ambiguity and complexity using internal processes including managing the environment and titrating moment-to-moment care. CONCLUSIONS While physical suffering may be remedied with direct nursing care, holistically attending to EOL suffering in the PICU requires both bolstering external processes and strengthening PICU nurses' internal resources. Improving psychosocial training and optimizing interprofessional care systems could better support dying children and their families.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; National Clinician Scholars Program (E.G.B.), Yale Schools of Medicine and Public Health, New Haven, Connecticut.
| | - Ijeoma Julie Eche-Ugwu
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services(I.J.E.U.), Dana-Farber Cancer Institute, Boston, Massachussetts
| | - Danielle D DeCourcey
- Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Division of Medical Critical Care (D.D.D.), Boston Children's Hospital, Boston, Massachussetts
| | - Joanne Wolfe
- Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Department of Pediatrics (J.W.), Massachusetts General Hospital and Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachussetts
| | - Pamela S Hinds
- Department of Nursing Science (P.H.), Professional Practice and Quality, Children's National Hospital, Washington, DC; Department of Pediatrics (P.H.), The George Washington University, Washington, DC
| | - Jennifer Snaman
- Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts
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Lamb C. Dying, dependency and death: Exploring palliative care access gaps for children. Wellcome Open Res 2024; 9:120. [PMID: 38779151 PMCID: PMC11109588 DOI: 10.12688/wellcomeopenres.20803.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 05/25/2024] Open
Abstract
Death has become a medicalized event. As such, end-of-life care has become entrenched in an over-reliance on individual patient autonomy to guide ethical decision making. Subsequently, the process of dying and the event of death are not primarily valued as life events - that is, as life-affirming phases of living. Rather, dying and death are viewed through the lens of medical options of when and how to die versus why dying and death are meaningful. This presents a problem for addressing the pediatric palliative care access gap and the Global Common Good. Specifically, in the context of important life events, one of which is death, we need space to be dependent on our inter-personal relationships to make crucial life decisions that affect our well-being. Recognizing dependency and inter-personalism is particularly important for pediatric populations. Children are uniquely placed to draw on their families and caregivers to make affirming life decisions in end-of-life care. This is particularly challenging to do in the Canadian context when Specialized Pediatric Palliative Care is not equitably available but options such as assisted death may soon be. Importantly, the meaning of death and dying is largely unexplored for this population. To advance ethical care at the end-of-life, more emphasis needs to be placed on the meaning that end of life events hold for Canadian children. In this paper I will outline the relevance of dependency and inter-personalism to attend to dying and death as meaningful phases of living for Canadian children and in relation to the pediatric palliative care access gap, the Global Common Good and Global Health Bioethics.
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Affiliation(s)
- Christina Lamb
- Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, T9SJA3, Canada
- CCBI, St. Michael's College, University of Toronto, Toronto, Ontario, M5S1J4, Canada
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Lamb CM, Ramer K, Amodu O, Groenenboom K. The meaning of dying and death for children, their carers, and families: a scoping review. BMC Palliat Care 2023; 22:194. [PMID: 38044451 PMCID: PMC10694886 DOI: 10.1186/s12904-023-01295-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/23/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The meaning of dying and death are underexplored concepts for Canadian children. Subsequently, it is unclear how children and stakeholders make meaning of children's holistic health needs at the end of life. METHODS A scoping review of the international scholarly literature was conducted. Thirteen data sources were searched to search the scholarly literature without date limits until January 2022. Studies were included on the basis of population: children (aged 0-19 years), families and caregivers; setting (in Canada and end-of-life or dying phases of living) and concepts of interest (dying and death). RESULTS Of the 7377 studies identified, 12 were included for data extraction and content thematic analysis. The themes and subthemes include: 1) valuing the whole person; 2) living while dying; 3) authentic death talk; 4) a supportive approach (with lack and presence of support as subthemes); and, 5) a personalist approach. CONCLUSIONS There is a pressing need for research into the meaning of dying and death for children, their carers and families in Canada. Lack of holistic care, authentic death talk, specialized pediatric palliative care providers, a personalist approach and communities of support present major gaps in care for Canadian children. Research is urgently needed to address these knowledge gaps to generate policy and support practice for dying children in Canada.
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Affiliation(s)
- Christina M Lamb
- St. Michael's College, University of Toronto, Toronto, ON, Canada, 81 St. Mary Street, M5S 1J4.
- Athabasca University, Athabasca, AB, Canada.
| | - Kianna Ramer
- Stollery Children's Hospital, Edmonton, AB, Canada
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Crowe L, Young J, Smith AC, Haydon HM. Factors that may threaten or protect the wellbeing of staff working in paediatric intensive care environments. Intensive Crit Care Nurs 2023; 78:103476. [PMID: 37379677 DOI: 10.1016/j.iccn.2023.103476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/25/2023] [Accepted: 06/05/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE This study explored the risk and protective factors for wellbeing from the perspectives of multidisciplinary paediatric intensive care unit staff. DESIGN Using a qualitative, descriptive study design we purposively recruited a sample of nurses, physicians, and allied health professionals to participate in semi-structured interviews which explored staff perceptions of risk and protective factors relating to their daily paediatric intensive care roles. Data was analysed using thematic analysis. SETTING Four paediatric intensive care units in Australia. FINDINGS Twenty staff were recruited. Braun and Clarke's thematic analysis approach identified perceived risks for wellbeing included a lack of preparation for the role, and clinical situations that contributed to psychological distress, including perceived worst shift, moral distress, non-accidental injuries, and isolation. Themes perceived as protective to wellbeing included: finding the work stimulating and meaningful, belonging to the team, and using humour. CONCLUSION Staff perceptions of wellbeing in the paediatric intensive care unit suggested that risk factors often co-existed simultaneously with protective factors. These results are not consistent with the notion that wellbeing as a phenomenon can be considered on a risk-protection continuum. Strategies that enhance this work as meaningful and stimulating, promote a sense of belonging to the team, and support the use of humour, may assist health professionals to achieve a balance between risk and protective factors for wellbeing. IMPLICATIONS FOR CLINICAL PRACTICE Education and training on end-of-life care, and how to have difficult conversations and manage the consistent psychological distress of intensive care work, is essential at orientation and requires regular formal interventions. Experiencing the work as stimulating highlights the need for advanced scope of practice work. Opportunities for individual and team reflection about the meaning and purpose of their work, and ensuring staff feel valued and experience a sense of belonging to the team, are critical to the intensive care context.
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Affiliation(s)
- Liz Crowe
- Centre for Online Health, The University of Queensland, Brisbane, Australia; Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
| | - Jeanine Young
- Centre for Online Health, The University of Queensland, Brisbane, Australia; Centre for Health Services Research, The University of Queensland, Brisbane, Australia; School of Health, University of the Sunshine Coast, Australia.
| | - Anthony C Smith
- Centre for Online Health, The University of Queensland, Brisbane, Australia; School of Health, University of the Sunshine Coast, Australia; Centre for Innovative Medical Technology, University of Southern Denmark, Odense, Denmark.
| | - Helen M Haydon
- Centre for Online Health, The University of Queensland, Brisbane, Australia; Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
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Chatmon BN, Richoux D, Sweeney B. The Impact of End-of-Life Care Among Nurses Working in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2023; 35:275-286. [PMID: 37532381 DOI: 10.1016/j.cnc.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Health care providers caring for patients at the end of life (EOL) are faced with a multitude of emotions such as guilt, anger, sadness, and helplessness. Because of the negative impact of initiating EOL care (EOLC) to the pediatric population, organizations must be proactive in instituting education and resources on EOLC. They must also provide advanced skills to nurses who take care of patients at their EOL. Understanding the consequences of providing EOL care to patients in the pediatric intensive care unit allows for better allocation of resources and support services for nurses. This improves patient outcomes and nurse retention.
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Affiliation(s)
- Benita N Chatmon
- Louisiana State University Health Sciences Center-New Orleans, School of Nursing, 1900 Gravier Street, Room 5B14, New Orleans, LA 70112, USA.
| | - Dianne Richoux
- Nicholls State University, School of Nursing, 906 East 1st Street, Thibodaux, LA 70301, USA
| | - Brittany Sweeney
- Nicholls State University, School of Nursing, 906 East 1st Street, Thibodaux, LA 70301, USA
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Broden EG, Mazzola E, DeCourcey DD, Blume ED, Wolfe J, Snaman JM. The roles of preparation, location, and palliative care involvement in parent-perceived child suffering at the end of life. J Pediatr Nurs 2023; 72:e166-e173. [PMID: 37355461 DOI: 10.1016/j.pedn.2023.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Parents' perceptions of their child's suffering affect their bereavement experience. Identifying factors that shape parental perceptions of suffering could help build effective supportive interventions for children and parents navigating EOL and grief. We aimed to compare parent-perceived child suffering between diagnostic groups and identify related factors. DESIGN AND METHODS We combined databases from 3 surveys of parents whose children who died following cancer, a complex chronic condition (CCC), or advanced heart disease. We built multivariable logistic regression models to identify relationships between parent-perceived child suffering and parent/child, illness experience, and care-related factors. RESULTS Among 277 parents, 41% rated their child's suffering as moderate or high. Fifty-seven percent of parents whose child died from cancer reported that their child suffered "a lot" or "a great deal" at EOL, compared to 33% whose child died from a CCC, and 17% whose child died from heart disease (P < 0.001). Preparation for EOL symptoms was associated with decreased parent-perceived child suffering in multivariable modeling, with parents who were prepared for EOL 68% less likely to rate their child's suffering as high compared to those who felt unprepared (AOR: 0.32, CI [0.13-0.77], P = 0.013). CONCLUSIONS Preparing families for their child's EOL may help mitigate lingering perceptions of suffering. Operationalizing preparation is crucial to optimizing family support during EOL care. IMPLICATIONS TO PRACTICE Preparation for symptoms, and access to resources, including medical/psychosocial interventions and staff, may help ease parental perception of EOL suffering. Clinicians should prioritize preparing families for what to expect during a child's dying process.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Division of Medical Critical Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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