CommunicationCauses of moral distress in the intensive care unit: A qualitative study☆
Introduction
Moral distress is the anger, frustration, guilt, and powerlessness that health care professionals experience when they are unable to practice according to their ethical standards [1], [2], [3], [4]. Empirical studies identify significant prevalence and high levels of moral distress in nursing practice [3], [5] and have linked moral distress to burnout and attrition [6], [7], [8]. Recent research has explored moral distress in other health care disciplines, with similar findings [1], [9], [10], [11], [12], [13]. Quantitative and qualitative studies show that moral distress has a profound effect on nurses and other health care professionals as well as on the quality of interdisciplinary team workplaces and the safety of patients [14], [15].
Although moral distress can be evaluated by both quantitative [5], [11], [15], [16], [17] and qualitative [10], [12], [13], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] means, there have been few qualitative studies of moral distress in intensive care unit (ICU) professionals [20], [26], [33], [34], [35], and none that have addressed moral distress in all ICU professionals in both community and tertiary ICUs. Therefore, the purpose of this study was to examine the causes and consequences of moral distress in diverse members of the ICU team in both community and tertiary ICUs. This article describes the causes of moral distress.
Section snippets
Materials and methods
A study on moral distress in ICUs was conducted in all 13 ICUs in the Vancouver area in British Columbia, Canada, in 2011 and 2012. First, a quantitative survey was completed by nurses, physicians, and other health professionals in all of the participating units [36]. Then, all ICU clinical staff in 3 of the participating hospitals (see Supplementary Digital Content for selection criteria) were invited to participate in focus groups to address causes and consequences of moral distress. Focus
Results
A total of 10 focus groups and 4 interviews were conducted. At each of the 3 hospitals, 1 focus group was conducted with each provider type, and a fourth group was conducted with clinical nurse leaders at one hospital. The interviews included 3 nurses and 1 other health professional. A total of 56 providers participated in the focus groups (Table 1). In the following description, quotations from participants are included verbatim except where clarifications are required or to maintain
Discussion
Focus groups with health care providers in 3 ICUs revealed many causes of moral distress. The causes mentioned in the most focus groups were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), and poor communication. The causes that were mentioned most frequently were concerns about the care provided by other health care workers, inconsistent care plans, and issues around end-of-life decision making. Our finding
Conclusions
Causes of moral distress can broadly be categorized into 8 categories: quality of care, amount of care provided, inconsistent care plans, end-of-life decision making, poor communication, interactions/conflict between ICU staff and family, recommendations for patient care ignored by other staff, and lack of support or resources. Interventions to address moral distress should consider these specific causes and the target groups and settings where they apply.
Acknowledgments
The authors thank all of the health care professionals who participated voluntarily in this project and Sarah Shepherd for organizing the focus groups.
Financial support: Canadian Institutes for Health Research (funding reference no. 106278), Providence Health Care Research Institute, Center for Health Evaluation and Outcome Sciences, St Paul's Hospital Foundation, BC Patient Safety and Quality Council, BC Nurses' Union, and BC Chair in Patient Safety.
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2022, Intensive and Critical Care NursingCitation Excerpt :Psychological and emotional responses associated with moral distress include feelings of powerlessness, self-blame, anger, frustration, and discouragement (Rodney, 2013), burnout (Sajjadi et al., 2017), anxiety and depression (Lamiani et al., 2017; Oh and Gastmans, 2015; Rittenmeyer and Huffman, 2009), deterioration of morale and teamwork, decreases in the quality of care, challenges related to patient safety (Rodney, 2017) and desire to leave the job (Fernandez-Parsons et al., 2013). Intensive care units are one of the departments where moral distress has been studied most extensively (Bruce et al., 2015; Henrich et al., 2016; Meltzer and Huckabay, 2004). In these units, situations that facilitate this emotional state include ethical dilemmas with critically ill patients, the use of technology and life support, patients who require withdrawing or withholding treatment, and clinical actions that could imply futile medical care (Hiler, et al., 2018; Mealer and Moss, 2016; Piers et al., 2011).
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None of the authors has any financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.