Moral distress: The unmeasured catalyst in preventing catheter-associated bloodstream infections in neonatal ICUs – Response to Lin & Huang

Objectives:Moral distress (MD), which is affected by several factors such as futile care provision and is considered the cause of adverse effects such as job dissatisfaction and decreased care quality, is a new concept attracting increasing academic interest. This study aims to assess the correlation between nurses’ perception of futile care and MD in neonatal care units.Material and Methods:This descriptive-correlational study was carried out among 115 nurses working in the neonatal intensive care units and neonatal special care units of two hospitals in West Azerbaijan Province during 2020. A demographic information form, the 21-item MD-Pediatric version scale, and the 17-item perception of futile care questionnaire were used to collect data and analysed using SPSS 16 software.Results:The results confirmed the direct correlation between MD and the perception of futile care. In addition, MD and the nurses’ perceptions of futile care were estimated to be moderate.Conclusion:The results of this study provide evidence to emphasise the need for further studies to investigate other causes of MD in neonatal units and find the solutions to make the work environment more ethical. Furthermore, the results provide the platform needed for hospital and university managers to make the necessary decisions and create the required changes in the educational curriculum of nursing students and provide the appropriate courses for neonatal unit nurses to improve their ability to cope with the MD caused by providing futile care.

BackgroundMoral distress is the experience of knowing what ethically right action to take, but being unable to act accordingly, due to external factors. It is an experience common to providers working in the neonatal intensive care unit (NICU) where care for infants, often born at the edges of viability or with other life-limiting diagnoses, includes life and death medical decision-making in the context of uncertain prognoses. Palliative care, which aims to reduce suffering, can assist with staff moral distress by providing space for conversations regarding goals-of-care and end-of-life decision making.MethodsThe palliative care and NICU teams co-developed a weekly, case-based conference to discuss palliative care domains of high-risk newborns including pain and symptom management, goals of care, spiritual support, and psychosocial strengths and challenges. The Moral Distress Thermometer (MDT) and the Moral Distress Scale-Revised (MDS-R) were collected at baseline and at 6- and 12-months post-intervention implementation. Quantitative and qualitative analyses were employed as appropriate.ResultsOne-hundred thirty-seven participants completed both surveys at baseline including 46 physician/advanced practice providers (MD/APPs) and 91 registered nurses/other health professionals (RN/OHPs). There were statistically significant improvements in both the mean MDT scores and the mean MDS-R for the overall cohort and specifically for the RN/OHP group from baseline to 12-months post-intervention. There was a trend towards improvement on these measures among the MD/APP cohort. Qualitative analysis of the free-text responses revealed several themes describing moral distress in the NICU. Themes common to both groups included: futile/non-beneficial care, prognostic uncertainty and prognostic communication, team conflict, institutional constraints and cultural bias. The theme, “End-of-life (EOL) care inconsistent with personal values” emerged among the RN/OHPs. RN/OHPs experiences were shaped by their proximity to the patient and their role as patient advocate. The MD/APP group reported more cognitive and decisional distress.ConclusionA NICU and palliative care-weekly-collaborative conference resulted in significantly decreased moral distress among NICU staff. Qualitative data revealed that both prolonging life with life-sustaining medical therapies (LSMTs) and ending it by withdrawing LSMTs in the context of prognostic uncertainty and institutional constraints creates significant moral distress among staff. Palliative care and NICU programs should consider implementing regular interdisciplinary collaborative conferences to address this distress.

ObjectiveTo review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).DesignPubmed, EBSCO (Academic Search Complete, CINAHL...

BackgroundThe hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation.MethodsThe present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis.ResultsThree themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists’ caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint.ConclusionsIn general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

Managing moral distress and complex ethical challenges in the NICU.

Moral distress has been identified in multiple clinical settings especially in critical care areas. The neonatal intensive care unit (NICU) has frequent situations in which moral distress may occur including providing palliative care. The purpose of this integrative review was to determine the relationship between the provision of palliative care in a NICU and nurses' moral distress. The evidence reviewed supports that moral distress does occur with the provision of neonatal palliative care. An interdisciplinary care team, an established protocol, and educational interventions may decrease moral distress in nurses providing end-of-life care to infants in the NICU.

BackgroundWorking as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration.MethodsThis prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach.ResultsA variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists’ moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists’ constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists’ moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant’s best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists’ colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists’ constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time.ConclusionsWe concluded that neonatologists’ moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

Background:Nurses working in neonatal intensive care units are increasingly faced with a moral distress due to nature of their profession. It is anticipated that this amount of moral distress can have a negative effect on their affection and compassion towards the patient. The aim of this study was to determine the correlation between moral distress and compassion fatigue in NICU Nurses.Method:This descriptive correlational study was conducted with 172 nurses working in the neonatal intensive care unit in educational hospitals in 2016. Data were collected using demographic information form, Corley’s moral distress questionnaire, Figley’s compassion fatigue. Data were analyzed by descriptive and inferential statistical tests.Findings:The mean score of moral distress in the range (0-5) in the repetition dimension was 0.62 ± 2.01 and in the dimension of intensity was 0.89 ± 3.11. The average of compassion fatigue in the range (0-6) was 0.50 ± 3.94, normal to high. In examining the dimensions of compassion fatigue, the highest score belonged to the degree of compassion satisfaction 0.82 ± 4.48 and then the exhaustion 0.53 ± 3.70 and post-traumatic stress 0.84 ± 3.63.Conclusion:The results of this study indicated that there was a significant positive correlation between the intensity of moral distress and compassion fatigue (P= 0.001 r= 0.436), but between the frequency of moral distress and compassion fatigue, there was no relationship (P= 0.142 r= 0.137). Significant correlation was found between age (r = 0.22), nursing experience (r = 0.24) and work experience in neonatal intensive care unit (r = 0.187) with compassion fatigue. The results of this study indicate that extreme moral distress can be related with compassion fatigue.

To elucidate the meaning of moral distress in nurses caring for critically ill neonates. Qualitative study using Husserl's descriptive phenomenology. Between April and December 2022, unstructured interviews were conducted with 11 nurses with at least 3 years of neonatal intensive care unit experience in Japan. They were asked to recall experiences of moral distress and to speak freely about their thoughts and feelings at the time. The analysis followed Colaizzi's seven-step method. Three themes ('organisational constraints', 'regret' and 'unshared experiences') and seven subtheme clusters were extracted from the nurses' narratives of moral distress, which was the basis of trauma. Subtheme clusters included 'wavering beliefs', 'guilt associated with the death of a child', 'powerlessness at being unable to help one's family' and 'mismatch with the perceptions and feelings of the family'. Nurses experience various morally distressing events, but these are processed only as personal problems and give rise to feelings of self-negation. Therefore, trauma can develop as a result of experiences related to decision-making and the child's best interests. There is a need to improve nurses' moral resilience and ensure their psychological safety to alleviate moral distress. This study clarifies nurses' roles within the neonatal intensive care unit, potentially helping them to handle life-and-death issues and cope with feelings of moral distress. This study elucidated the meanings of powerlessness underlying the moral distress experienced by neonatal intensive care unit nurses. These results will contribute to releasing suppressed feelings and thoughts and alleviating unavoidable moral distress in this setting. This study was performed in accordance with the COREQ guidelines. Nurses with experience in neonatal intensive care unit nursing participated as interviewees. They also verified the credibility of survey results and ensured analytical rigour.

Background Moral distress is prevalent within the neonatal intensive care unit (NICU) and can negatively affect clinicians. Studies have evaluated the causes of moral distress and interventions to mitigate its harmful effects. However, the effects of participating in moral distress studies have not been evaluated. Objective To evaluate the impact of participation in a longitudinal, non-intervention research project on moral distress in the NICU. Design Clinicians who previously participated in an 18-month longitudinal research study on moral distress at two NICUs were invited to complete a questionnaire on the impact of participation. The original study required regular completion of surveys that sought predictions of death, disability and the intensity/nature of moral distress experienced by clinicians caring for extremely preterm babies. Individual and unit-wide effects were explored. Free-text responses to open-ended questions were analyzed using inductive content analysis. Results A total of 249/463 (53%) eligible clinicians participated. Participation in the original 18-month study was perceived as having a positive impact by 58% of respondents. Clinicians found articulating their views therapeutic (76%) and useful in clarifying personal opinions about the babies (85%). Free-text responses revealed the research stimulated increased reflection, validated feelings and increased dialogue amongst clinicians. Respondents generally did not find participation distressing (70%). However, a small number of physicians felt the focus of discussion shifted from the baby to the clinicians. Intensity and prevalence of moral distress did not significantly change over the 18-month period. Conclusions Participating in moral distress research prompted regular reflection regarding attitudes toward fragile patients, improving ethical awareness. This is useful in clarifying personal views that may influence patient care. Participation also enhanced communication around difficult clinical scenarios and improved provider satisfaction. These factors are insufficient to significantly reduce moral distress in isolation.

Moral distress is a significant problem for nurses (RNs). It has physical, emotional, and psychological sequelae and a negative impact on the quality, quantity, and cost of patient care. Moral distress leads to loss of moral integrity and job dissatisfaction and is a major cause of burnout and RNs leaving the profession. The majority of research has been carried out with RNs working in acute care, adult inpatient settings, especially critical care areas. Neonatal intensive care unit (NICU) RNs confront ethically and morally challenging situations on a regular basis. There are limited data clarifying their moral distress. The purpose of this study was to describe the moral distress of RNs working in NICUs and to identify the situations that are associated with their moral distress. What are the intensity and frequency of moral distress in NICU RNs, what situations are associated with moral distress in NICU RNs, and what personal characteristics are correlated with moral distress in NICU RNs? This descriptive, correlational study was conducted with RNs in the level III NICUs of a healthcare system in the northeastern United States. Participation was voluntary and anonymous. A convenience sample of RNs completed a demographic data sheet and the Moral Distress Scale Neonatal-Pediatric Version. Data were collected during October 2008. Ninety-four of 196 eligible RNs (48%) participated in the study. As a whole, the subjects did not perceive that the situations described in the instrument occurred frequently and did not cause great distress. Subjects' individual scores displayed wide variations for all dimensions of moral distress ranging from low to high, indicating that individual RNs may be experiencing moral distress.The situations receiving the highest scores are comparable with the areas that are problematic for other critical care nurses as described in the literature. In this study, 4 RN characteristics were significantly related to moral distress: the desire to leave their current position, lack of spirituality, altered approach to patient care, and considering but not leaving a previous job because of moral distress. The results of this study add to the understanding of the moral distress in NICU RNs. The data will provide evidence for eventual psychometric testing and factor analysis of the Moral Distress Scale Neonatal-Pediatric Version.

To quantify moral distress in neonatal ICU and PICU clinicians and to identify associated factors. A national cross-sectional survey of clinicians working in an neonatal ICU or PICU. Moral distress was assessed with the Moral Distress Scale-Revised and by self-rating. Depersonalization was assessed on the subscale of the Maslach Burnout Inventory. Respondents reported their attendance at each of six hospital supports that may serve to mitigate moral distress in frontline staff. Analyses compared outcomes across respondent characteristics and hierarchical linear regression evaluated individual, ICU, hospital, and regional effects. Eligible ICUs were PICUs and level-3 neonatal ICUs in Canada. Eligible participants had worked in the participating ICU for more than 3 months. None. We identified 54 eligible ICUs from 31 hospitals. Forty-nine Canadian neonatal ICUs and PICUs (91%) contributed 2,852 complete responses for a 45.2% response rate. Most respondents were nurses (64.9%) or from a neonatal ICU (66.5%). The median and interquartile range Moral Distress Scale-Revised were 79 (52-113); 997 respondents (34.2%) had Moral Distress Scale-Revised scores greater than or equal to 100, and 234 respondents (8.3%) strongly agreed that work caused them significant moral distress. Nurses had a median (interquartile range) Moral Distress Scale-Revised score of 85 (57-121), 19 points higher than physicians and 8 points higher than respiratory therapists (p < 0.0001). Moral Distress Scale-Revised scores increased from 53 (35-79) for those working in ICU less than 1 year to 83 (54-120) in those working in ICU more than 30 years (p < 0.0001); 22.5% reported high degrees of depersonalization, which was associated with moral distress (p < 0.0001). Variability in Moral Distress Scale-Revised scores was explained by individual-level (92%), hospital-level (5%), and ICU-level effects (1%). Frequency of participation in potentially mitigating hospital supports had small effects (< 10 points) on mean Moral Distress Scale-Revised scores. Moral distress is common in clinicians working in ICUs for children. Addressing moral distress will require interventions tailored to individuals in higher-risk groups.

In the neonatal intensive care unit (NICU), nurses care for premature and critically ill neonates, interact with parents, and make clinical decisions regarding the treatment of neonates in life-threatening conditions. The challenges of managing unstable conditions and resuscitation decisions can cause moral distress in nurses. This study aims to determine the relationship between clinical decision-making and moral distress in NICU nurses. This cross-sectional, multicenter, descriptive correlational study involved 190 nurses working in 7 NICUs across hospitals in Khorramabad and Semnan in 2023. Data were collected using demographic questionnaires, the Clinical Decision-Making Laurie Scale (2001), and the Moral Distress Scale-Revised (MDS-R). All nurses in these NICUs were female. No significant correlation was found between clinical decision-making and moral distress (r=-0.03, P =.684). The moral distress score was low. In decision-making, 57.9% of nurses exhibited intuitive analysis (understanding without a rationale). Multiple linear regression analysis revealed that age, education level, and job position were significantly related to clinical decision-making; and being married and having children were inversely correlated with moral distress. 20% of nurses exhibited interpretive intuitive clinical decision-making, which involves care complexities, cognitive understanding, and task-based decisions. Nursing managers should focus on refining these decision-making strategies for NICU nurses. Given the importance of clinical decision-making in the NICU, future research should use quantitative and qualitative methods to explore the decision-making processes and moral distress in NICU nurses.

To measure the level of moral distress in PICU and neonatal ICU health practitioners, and to describe the relationship of moral distress with demographic factors, burnout, and uncertainty. Cross-sectional survey. A large pediatric tertiary care center. Neonatal ICU and PICU health practitioners with at least 3 months of ICU experience. A 41-item questionnaire examining moral distress, burnout, and uncertainty. The main outcome was moral distress measured with the Revised Moral Distress Scale. Secondary outcomes were frequency and intensity Revised Moral Distress Scale subscores, burnout measured with the Maslach Burnout Inventory depersonalization subscale, and uncertainty measured with questions adapted from Mishel's Parent Perception of Uncertainty Scale. Linear regression models were used to examine associations between participant characteristics and the measures of moral distress, burnout, and uncertainty. Two-hundred six analyzable surveys were returned. The median Revised Moral Distress Scale score was 96.5 (interquartile range, 69-133), and 58% of respondents reported significant work-related moral distress. Revised Moral Distress Scale items involving end-of-life care and communication scored highest. Moral distress was positively associated with burnout (r = 0.27; p < 0.001) and uncertainty (r = 0.04; p = 0.008) and inversely associated with perceived hospital supportiveness (r = 0.18; p < 0.001). Nurses reported higher moral distress intensity than physicians (Revised Moral Distress Scale intensity subscores: 57.3 vs 44.7; p = 0.002). In nurses only, moral distress was positively associated with increasing years of ICU experience (p = 0.02) and uncertainty about whether their care was of benefit (r = 0.11; p < 0.001) and inversely associated with uncertainty about a child's prognosis (r = 0.03; p = 0.03). In this single-center, cross-sectional study, we found that moral distress is present in PICU and neonatal ICU health practitioners and is correlated with burnout, uncertainty, and feeling unsupported.

As Korean neonatal nurses frequently experience the deaths of infants, moral distress occurs when they provide end-of-life care to the infants and their families. Although they need to care for the patients' deaths and consequently experience burnout and turnover due to moral distress from the situation, there is a lack of a support for nurses. Moreover, not much information is available on the moral distress of neonatal nurses. There is a need to better understand Korean neonatal nurses' moral distress to develop and implement appropriate supports. This study aimed to describe nurses' experience of moral distress when they provide end-of-life care to infants and their families in neonatal intensive care units. This is a secondary analysis qualitative study. Content analysis was performed based on Corley's theory of moral distress to develop a codebook and identify themes regarding moral distress among the nurses. Qualitative data were collected from 20 nurses working in two NICUs in Seoul, South Korea. The original study obtained permission from a university's institutional review board (IRB). This secondary analysis study obtained the exemption from another university's IRB. Nurses' participation was voluntary and confidential. The nurses' moral distress was derived when they faced moral constraints and/or moral conflicts. Two distinct categories of moral constraints and four distinct categories of moral conflicts were identified among the neonatal nurses. In addition, impacts of moral distress on patients and nurses were identified. This study identified occasions neonatal nurses experience moral distress, and thus can guide in developing and implementing effective interventions to decrease their moral distress and improve their resilience in end-of-life care by providing insight into neonatal nurses' needs for support in end-of-life care.