Discussion Guide for the Hua Article.

Abstract

Moral distress is a negative psychological response related to perceived or actual lack of agency in morally charged situations. For example, clinicians may experience moral distress when providing care antithetical to their personal belief systems and professional values. Moral distress exacerbates clinicians’ burnout, job dissatisfaction, and work attrition—all of which may compromise safe and effective patient care. High levels of moral distress are commonly reported in critical care environments during the provision of life-sustaining interventions; however, little is known about the prevalence of moral distress among clinicians providing care for patients undergoing mechanical circulatory support (MCS). Mechanical circulatory support, which includes both left and right ventricular assist devices as well as extracorporeal membrane oxygenation, continues to expand in therapeutic scope and lengthen patients’ life spans. Yet MCS complications, such as cerebrovascular events, bleeding, and infection, can limit MCS’s prognostic utility and compromise the patient’s quality of life. Much like life-sustaining therapies provided during critical illness, patient care related to MCS provision may contribute to moral distress for clinicians. However, empirical evidence describing moral distress in this population is nascent. Therefore, the purpose of this study was to measure moral distress levels in clinicians who commonly care for patients with MCS and to examine associations between moral distress and clinician outcomes to understand how MCS may uniquely contribute to moral distress.This prospective, cross-sectional study recruited critical care physicians, nurses, and advanced practice providers (APPs) from a medical intensive care unit (ICU) and a cardiothoracic ICU at an academic medical center in New York City. Clinician trainees were excluded from participation. Electronic and paper surveys were used to collect clinicians’ sociodemographic information, moral distress levels, burnout symptoms, related outcomes, and preferred interventions for moral distress support. The final sample contained 102 clinicians, most of whom were nurses (n = 67). Most of the participants were younger than 45 years (80%), White (50%), and had at least 5 years of practice experience (72%). Moral distress levels were higher among those who self-identified as females, Asian, or single/divorced and among those with more than 10 years of practice experience. After adjustment for sex, race, relationship status, and practice experience, nurses reported more moral distress than physicians or APPs reported. Similarly, those reporting symptoms of burnout and those considering leaving their position reported greater moral distress. Moral distress levels were greater among clinicians caring for patients receiving MCS, compared with routine patient assignments, but the moral distress levels were lower than those reported by clinicians providing care for chronically critically ill patients or patients with multisystem organ failure. Overall, participating clinicians preferred increased implementation of palliative care and ethics consultations, as well as debriefing sessions, to alleviate moral distress.May Hua, MD, MS, the corresponding author for this article, provides additional information about this study: “The motivation for this study arose from stakeholder engagement surrounding a quality improvement project I undertook to implement a palliative care consultation trigger … for patients requiring mechanical circulatory support.” During this meeting, the ICU nurses described the moral distress of caring for patients receiving MCS. Dr Hua acknowledges, “While anyone working in the ICU knows that ICU clinicians all experience moral distress at times, anecdotally, it seemed that some … felt that this particular population … [was] particularly challenging in this regard.” Therefore, to acknowledge and understand these anecdotal experiences, as well as how to best support the ICU providers, Dr Hua and her team conducted this study.Dr Hua expresses how “incredibly proud” she is of the assembled team for this project, which included critical care physicians, nurses, and research staff, each of whom “brought unique strengths and viewpoints to the conduct of the research.” Dr Hua encourages less-experienced investigators “to actively think about how team members may complement one another and serve in different roles.” In research, complementary teams allow for creative and efficient problem solving. For example, Dr Hua shares “some of our ICU nurse participants stated how difficult it was for them to find time to fill out the survey instrument[s]. One way that we addressed these challenges was by having paper surveys in addition to the electronic one, which allowed flexibility for participants to be able to complete the survey in whatever way was best suited for them.”Researchers may also encounter unexpected circumstances that may not only inform the present work but open up a new line of questioning. Dr Hua adds, “One of the unexpected difficulties that we encountered was that for some clinicians, filling the survey out was in and of itself a triggering experience. I had some participants come up to me and relay how they had to fill the survey out over time and take breaks because the questions made them think of a particular experience or specific patients. However, these same participants often stated how important they felt it was to be doing this research and this work.” Although these unexpected findings may initially raise concerns for researchers, Dr Hua encourages emerging researchers to “pay attention to those moments . . . [when] you are taken aback or surprised. They are not quite ‘aha!’ moments, but I think there’s often an interesting question underlying those instances that can be turned into a research project.”Given the overall findings from this study, Dr Hua proposes that MCS may “not in and of itself [be] a factor that may increase moral distress” but that “its use may result in a greater number of patients that go on to have prolonged critical illness.” She adds that it is important for “those in clinical leadership, and for us as ICU clinicians, to be aware of how providing clinical care in the face of such prognostic uncertainty can affect clinician well-being.” Motivated by her own research, Dr Hua “make[s] an effort to check in with nurses and other clinicians caring for patients who are severely ill, knowing these situations are more likely to engender moral distress.” Dr Hua’s vision for this area of research highlights the work still to be done: “I believe that we are at the beginning of our journey to better understand how to support clinicians who may feel morally distressed when providing clinical care.”This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.May Hua, MD, MS, has been an anesthesiologist and critical care intensivist for almost 10 years. Clinically, her primary practice setting is within surgical and cardiothoracic ICUs. As a physician scientist, she studies how to improve the quality of critical care through evidence-based palliative and end-of-life care. Dr Hua shares, “My clinical experiences have always been central to my research questions, they are what drove me to pursue research in my particular area, and they are the inspiration for many of the studies that I have conducted over the years.” She concludes, ”Using clinical experiences as inspiration often makes the most interesting studies, and I have had multiple instances when an anecdote or a random thought led to a study or project.”