Provider Moral Distress Research Articles

State Abortion Policy and Provider Moral Distress Levels After Dobbs [ID 2683541

INTRODUCTION: Moral distress occurs when individuals feel powerless to carry out ethically correct actions, including when prevented from providing necessary health care. We aimed to measure self-reported moral distress levels among abortion providers after the Dobbs decision and to assess differences by state-level abortion policy. METHODS: In 2023, we surveyed abortion providers nationally through professional listervs. Institutional review board-exempt surveys queried demographics, practice characteristics, and the Moral Distress Thermometer (MDT), a validated psychometric tool that measures moral distress level from 0 (lowest) to 10 (highest). Providers reported whether their moral distress level had changed since Dobbs. We assessed overall moral distress level and differences by state restrictiveness (using Guttmacher’s classifications) using one-way ANOVA (continuous variables) and chi-squared tests (categorical variables). RESULTS: In total, 253 practitioners completed the MDT for one or more states where they practiced (N=285 MDTs analyzed), with 56.8% of responses for “protective” states and 43.2% for “restrictive” states. Moral distress levels ranged from 0 to 10 (mean=5.09) and were twice as high for providers in restrictive compared to protective states (mean=7.15 versus 3.52; P<.001). Change in distress post Dobbs differed by state restrictiveness: In restrictive states, 89.4% reported an increase compared to 71.6% in protective states (P<.01). CONCLUSION: Moral distress levels for abortion providers were high following Dobbs, and higher in restrictive states. Most providers experienced increased distress across policy contexts. Moral distress has been associated with burnout, errors in patient care, and attrition. High and increasing moral distress levels, especially in abortion restrictive states, may worsen provider shortages, and lead to poor patient outcomes.

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation.

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence. Moral distress will be significant in a dedicated pediatric trach/vent unit. The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy(MD/DOs), advanced practice practitioners (APPs), registered nurses(RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed. Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartilerange[IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively). Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs.APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

Walking a Tightrope: Balancing Continuity for Long-Stay Patients and Wellness for Clinicians in an Ever-Evolving Landscape.

Walking a Tightrope: Balancing Continuity for Long-Stay Patients and Wellness for Clinicians in an Ever-Evolving Landscape.

Why Does It Feel Different? Provider Moral Distress in Removing Unwanted Aggressive Intervention for Conscious Patients (TH123B)

Why Does It Feel Different? Provider Moral Distress in Removing Unwanted Aggressive Intervention for Conscious Patients (TH123B)

Hospitalists' Perceptions of Pediatric Mental Health Boarding: Quality of Care and Moral Distress.

Acute care hospitals increasingly provide care for youth experiencing mental health crises while they await transfer for psychiatric hospitalization. To inform quality improvement efforts, we aimed to characterize hospitalists' perceptions of health care quality during pediatric mental health boarding and their experiences of moral distress in caring for this population. In March 2021, we conducted a web-based survey of hospitalists who participate in the Pediatric Research in Inpatient Settings (PRIS) network. Closed- and open-ended questions queried the quality of care provided to youth during boarding and clinician experience of moral distress in caring for these youth. We iteratively coded qualitative data for emergent themes. Moral distress was measured using 11 items from the Measure of Moral Distress for Health Care Professionals (MMD-HP), which categorizes sources of moral distress into system-, team-, and patient-level factors. Eighty-eight of 111 PRIS site leaders (79%) and 76 of 383 other PRIS members (20%) responded, representing 12 community hospitals, 38 freestanding children's hospitals, and 35 children's hospitals in adult centers. Emergent themes related to health care quality included the following: access to psychiatric services; safety; standardized workflows; clinician training; compassion/patient engagement; and collaboration and disposition planning. Hospitals often lacked desired resources, resulting in poor perceived therapeutic value of care, limited patient engagement, and provider moral distress. Four of the 5 highest MMD-HP item scores were related to system-level factors. Hospitalists identified several foci for quality improvement and described significant moral distress in caring for youth experiencing boarding, particularly related to health system factors.

Emergency department staff perceptions about the care of children with mental health conditions

ObjectiveThe number of children with mental health (MH) conditions who present to the emergency department (ED) is increasing. This study aimed to gain insight into the lived experiences of ED staff caring for children with MH conditions and to understand perceptions of current ED resources and what is needed to optimize care. MethodsThis was a qualitative study informed by complexity science theory utilizing a phenomenological approach. We used purposeful sampling from urban and nonurban EDs with varying pediatric volume. Participants were pediatric emergency care coordinators and other ED staff. Semi-structured interviews were completed. The initial codebook was created using a concept driven approach. Constant comparative analysis and deductive reasoning was employed for thematic analysis. ResultsThematic saturation by consensus was achieved with 24 interviews. Analysis found an overarching theme of moral distress of ED staff, compounded by frustration with barriers to care and perceptions of negative impact on care of other ED patients. Participants suggested the need for creation of patient, caregiver, ED staff, and ED leadership resources to enhance care. ConclusionsED staff perceive children with MH conditions experience significant barriers to optimal care in the ED, which causes ED provider moral distress. Additionally, other ED patients are perceived to be subsequently negatively impacted. Our findings highlight urgency for funding for more resources that are dedicated to children in the ED setting to ensure both safe, patient-centered care, and to reduce the distress described by ED staff who care for them.

Distress and the Long-Stay Pediatric Intensive Care Unit Admission: A Longitudinal Study of Parents and the Medical Team.

Prolonged critical illness in children has emotional consequences for both parents and providers. In this observational cohort study, we longitudinally surveyed anxiety and depression in parents and moral distress in pediatric intensive care unit (PICU) providers (attendings, fellows, and bedside registered nurses) and explored their trajectories and relationships. Anxiety/depression and provider moral distress were measured using the Hospital Anxiety and Depression Scale and the Moral Distress Thermometer, respectively. The relationships of parental and provider distress were evaluated using Spearman's correlations, and their trajectories and potentially associated variables were explored using quadratic random slope and intercept models. Predetermined associated factors included demographic and clinical factors, including parent psychosocial risk and intubation status. We found parental anxiety and depression decreased over their child's admission, and parental psychosocial risk was significantly associated with anxiety (coefficient = 4.43, p < 0.001). Clinicians in different roles had different mean levels and trajectories of moral distress, with fellows reporting greater distress early in admissions and nurses later in admissions. Parental anxiety/depression and provider distress were significantly, though moderately, correlated. We conclude that anxiety and depression in parents of children with prolonged PICU admissions and the moral distress of their clinicians correlate and vary over time and by provider role.

Moral Distress Entangled: Patients and Providers in the COVID-19 Era.

Moral distress is defined as the inability to act according to one’s own core values. During the COVID-19 pandemic, moral distress in medical personnel has gained attention, related to the impact of pandemic-associated factors, such as the uncertainty of treatment options for the virus and the accelerated pace of deaths. Measures to provide aid and mitigate the long-term pandemic effect on providers are starting to be designed. Yet, little has been said about the moral distress experienced by patients and the relational and additive effect on provider moral distress. Pandemic-associated factors affecting moral distress in patients include the constraining effects of isolation on spiritual and religious traditions as well as the intentional separation of patients from their families. This paper will explore the idea that patients are suffering their own moral distress and further how this impacts the intensity of moral distress experienced by the providers—nurses and physicians. The paucity of research in this area with the implications on patient’s distress, decision making, and distress experienced by providers compels further investigation and analysis.

Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival.

Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. References and data were based on relevance and author consensus. We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Moral distress: Developing strategies from experience.

Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

Development and Retrospective Review of a Pediatric Ethics Consultation Service at a Large Academic Center.

The primary objective was to review pediatric ethics consultations (PECs) at a large academic health center over a nine year period, assessing demographics, ethical issues, and consultant intervention. The secondary objective was to describe the evolution of PECs at our institution. This was a retrospective review of Consultation Summary Sheets compiled for PECs at our Academic Health Center between January 2008 and April 2017. There were 165 PECs reviewed during the study period. Most consult requests came from the inpatient setting, with the Pediatric and Neonatal Intensive Care Units being the highest utilizers. Consultation utilization increased over the study period. The most common patient age was less than oneyear. Physicians were most likely to request consultation. Patient Best Interest, Withholding/Withdrawing of Life Sustaining Therapy, and Provider Moral Distress were ethical issues most commonly identified by the consultants. Making recommendations was the most common consultant intervention. The ethics consultation process evolved over time from informal provider discussions, to a hospital infant care review committee, to a pediatric only consultation service, to a combined adult/pediatric consultation service, with variable levels of salary support for consultants. Ethics consultation requests are growing at our institution. Similarities in identified ethical issues exist between our findings and existing literature, however meaningful comparisons remains elusive secondary to variability in approaches to investigation and reporting. A combined paid/volunteer/trainee ethics consultation service model appears sustainable and real time ethics consultation is feasible using this approach.

Stories from the Field: Provider Moral Distress and Ethical Dilemmas.

Stories from the Field: Provider Moral Distress and Ethical Dilemmas.

Another Look at the Persistent Moral Problem of Emergency Department Crowding

This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.

Counterpoint: Provider moral distress in end-of-life oncology care is a moral crutch.

Counterpoint: Provider moral distress in end-of-life oncology care is a moral crutch.

From “Longshot” to “Fantasy”: Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail

Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from “longshot” to “fantasy” is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.

Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU.

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.

Palliative Care and Moral Distress in the Intensive Care Unit

Moral distress is a harmful emotional experience that often afflicts health care providers who care for dying patients. First described among nurses, morally distressing situations are particularly common in critical care, where nurses and other providers can feel forced to prolong their patients’ d

Healthcare Provider Moral Distress as a Leadership Challenge

Healthcare leaders are responsible for using strategies to promote an organizational ethical climate. However, these strategies are limited in that they do not directly address healthcare provider moral distress. Since healthcare provider moral distress and the establishment of a positive ethical climate are both linked to an organization's ability to retain healthcare professionals and increase their level of job satisfaction, leaders have a corollary responsibility to address moral distress. We recommend that leaders should provide access to ethics education and resources, offer interventions such as ethics debriefings, establish ethics committees, and/or hire a bioethicist to develop ethics capacity and to assist with addressing healthcare provider moral distress.

Healthcare Provider Moral Distress as a Leadership Challenge

JONA's Healthcare Law, Ethics, and Regulation: October 2008 - Volume 10 - Issue 4 - p 98-99 doi: 10.1097/NHL.0b013e3181957ad9