Journal of Pediatric Nursing (2015) 30, 908–914
Moral Distress in Pediatric Healthcare Providers1 Karen Trotochaud MN, MA, RN a,⁎, Joyce Ramsey Coleman MBA, MS, RN, NEA-BC a,2 , Nicolas Krawiecki MD a,b , Courtney McCracken PhD b a
Children's Healthcare of Atlanta, Atlanta, GA Emory University, Atlanta, GA
b
Received 6 January 2014; revised 11 March 2015; accepted 12 March 2015
Key words: Moral distress; Pediatric providers; Intensive care
Pediatric providers across professions and clinical settings experience moral distress. Higher moral distress correlates with intent to leave for all professionals. Physicians as professional group had the highest moral distress. Intensive care nurses had the highest moral distress for nurses. While all providers describe distressing scenarios as disturbing, physicians report situations as occurring more frequently. The most distressing situations include requests for aggressive treatments not in child's best interest, poor team communication and lack of provider continuity. Understanding moral distress as experienced by all pediatric providers is needed to create interventions with a goal of reducing provider turnover. © 2015 Elsevier Inc. All rights reserved.
SAFE, HIGH QUALITY pediatric healthcare cannot exist without the retention of a prepared and experienced provider workforce. The growing problem of healthcare provider shortages, especially nurse shortages, is a national priority as identified in Institute of Medicine reports on the state of nursing (Finkelman & Kenner, 2012). The phenomenon of moral distress has been linked to job retention, a critical work force issue for healthcare organizations (Burston & Tuckett, 2012). The focus of this study is assessment of the degree of moral distress experienced by pediatric healthcare providers including nurses, physicians and other healthcare providers and the relationship of moral distress to healthcare provider job retention. Moral distress, defined as distress that occurs when constraints make it nearly impossible to pursue the right course of action (Jameton, 1984), is identified as a significant factor 1
affecting nurse satisfaction and retention (Allen et al., 2013; Houston et al., 2013; Pauley, Varcoe, & Storch, 2012). Wilkerson's (1987/88) Moral Distress Model (MDM) describes moral distress as a negative feeling state that results when an individual decides that an action is morally right but does not follow through with this action. In this model, the degree of distress experienced is significantly affected by the frequency of cases encountered and the ability of one to effectively cope with these encounters. Nursing turnover is a negative outcome of frequent encounters that are felt as very distressing. Root causes of moral distress can be internal to the caregiver (perceived powerlessness, lack of knowledge of alternatives) or external factors (poor staffing, limited administrative support, provider incompetence). Constraints can be embedded in the clinical situations themselves, like requests for futile or
Previous Presentations: Poster Presentations 1. 4th Annual Nursing Research Symposium, Children's Healthcare of Atlanta Atlanta, Georgia; May 8, 2013. 2. American Society for Bioethics and the Humanities 15th Annual Conference Atlanta, Georgia; October 24–27, 2013. ⁎ Corresponding author: Karen Trotochaud MN, MA, RN. E-mail address: [email protected]. 2 Present address: Texas Children’s Hospital, Houston, Texas. http://dx.doi.org/10.1016/j.pedn.2015.03.001 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Moral Distress in Pediatric Healthcare Providers Table 1 Physician Attending Resident Fellow Other Missing
909
Respondents by position for each professional group. n (%) 98 21 10 1 3
(73.7) (15.8) (7.5) (0.8) (2.3)
Nurse Novice (b 1 year) Colleague (N 1 year) Resource Leader (masters) Asst. nurse manager Clinical educator Nurse practitioner Other Missing
inappropriately aggressive treatment, inadequate informed consent, or witnessing false hope (Hamric, 2012). The impact of moral distress on providers includes emotional responses (anger, frustration, guilt) and physical disorders (headache, sleep dysfunctions). It can affect social relationships and contribute to avoidance behaviors in professional interactions (Gutierrez, 2005). An ongoing concern of healthcare organizations is the impact moral distress has on intent to leave one's clinical position. Moral distress contributes to nursing turnover and is directly correlated to nurses' intent to leave their clinical positions (Cavaliere, Daly, Dowling, & Montgomery, 2010; Corley, 1995; Hamric, Borchers, & Epstein, 2012). Although largely studied in providers who care for adult patients, moral distress is described in some pediatric nurses. Grief and moral distress are identified in pediatric intensive care unit (PICU) nurses working with children at the end of life (Davies et al., 1996; Lee & Dupree, 2008) and in neonatal intensive care unit (NICU) nurses related to resuscitation and outcome of premature infants (Janvier, Nadeau, Deschênes, Couture, & Barrington, 2007). When compared, nurses from adult intensive care units (ICUs) report somewhat higher moral distress than nurses from PICUs (Lawrence, 2011). In one study of pediatric oncology/hematology nurses, over 50% of the nurses report thinking about leaving their current clinical setting due to psychological reasons and moral distress (Lazzarin, Biondi, & Di Mauro, 2012). Recent reports identify moral distress in professionals other than nurses. Significant moral distress is identified in pediatric residents (Hilliard, Harrison, & Madden, 2007). Of physicians and nurses working in adult and pediatric ICUs, nurses are found to have higher moral distress compared to physicians (Hamric & Blackhall, 2007; Hamric et al., 2012). Two recent studies comparing moral distress in a variety of professionals working in differing clinical settings report moderate to high levels of moral distress in all disciplines with nurses reporting the highest overall level of distress (Allen et al., 2013; Houston et al., 2013). Using Wilkerson's (1987/88) MDM as the conceptual framework, this study seeks to better understand moral distress experienced by all pediatric providers. The objectives of this
n (%) 14 (2.4) 241 (41.8) 204 (35.4) 11 (1.9) 64 (11.1) 3 (0.5) 23 (4) 4 (0.7) 13 (2.3)
Other Respiratory therapist Social worker Physical therapist Speech pathologist Child life specialist Interpreter/Translator Occupational therapist Physician's assistant Chaplain School teacher Paramedic Other Missing
n (%) 43 23 21 13 12 9 5 5 4 3 1 14 6
(27) (14.5) (13.2) (8.2) (7.5) (5.7) (3.1) (3.1) (2.5) (1.9) (0.6) (8.8) (3.8)
study are: (1) to determine the degree of moral distress experienced by pediatric providers from different professional groups and working in different clinical settings; (2) to describe the relationship of moral distress to pediatric provider intent to leave; and (3) to identify specific situations more likely to be associated with pediatric provider moral distress.
Methods A descriptive study on moral distress in pediatric providers was conducted in April and May 2012. The setting was a large pediatric health system in the southeast that includes three children's hospitals with 60 pediatric specialties. A convenience sample included all registered nurses providing direct patient care (n = 1765); attending physicians with admitting privileges, subspecialty fellows, and pediatric residents (n =650); and other healthcare professionals including respiratory therapists, social workers, physical therapist, and other healthcare providers (n = 626). (Table 1 shows a full list of other providers by profession) The survey was sent via e-mail and providers were invited to complete the survey through a direct link to SurveyMonkey®. Participants were given 6 weeks to complete the survey with reminders sent to non-respondents at 2 and 4 weeks. The survey included demographic questions, two questions about intent to leave one's position, and the Moral Distress Scale-Revised (MDS-R©) (Hamric et al., 2012). This scale included 21 statements describing situations known to cause moral distress in clinical practice. Respondents rated each situation on two dimensions: (1) how frequently they experience it (0 = never to 4 = very frequently) and (2) how disturbing it is or would be for them (0 = none to 4 = great extent). Composite scores for each situation (range 0–16) were computed, and an overall moral distress score or MDS (range 0–336)) was calculated. An overall respondent MDS could be calculated only if greater than 90% of individual situation scores were completed. The Moral Distress Scale originally developed and validated by Corley (1995) in critical care nurses included 38 morally distressing situations rated on a 7-point Likert
910 scale, and it achieved internal reliability determined using Cronbach's alpha. Hamric and Blackhall (2007) revised this scale reducing it to include 21 situations using a Likert scale of 0–4 rating frequency and level of disturbance for each situation. Cronbach's alpha internal reliability was conducted using both nurses and physicians from adult and pediatric intensive care settings. Hamric et al. (2012) later adapted and tested a revised scale, MDS-R© , for use in multiple health care settings and with different professionals including physicians, nurses and other professionals with versions for adult and pediatric providers. An inter-rater agreement of 88% was achieved, and reliability using Cronbach's alpha of 0.88 for all participants was obtained using nurse and physician populations. Additional information on the validation of the MDS-R© is reported by Hamric et al. (2012). Permission was granted from Hamric for use of the scale in this study. Approval from the institutional review board was obtained, and a waiver of written consent was obtained. Participant responses were submitted anonymously directly to SurveyMonkey®. To maintain confidentiality no names or identifying information for respondents were collected.
Statistical Analysis All statistical analyses were conducted using SAS 9.2 for Windows (Cary, NC). Statistical significance was assessed at the 0.05 level. The primary outcome variable, MDS, was not normally distributed; therefore, a square-root transformation was applied to the original MDS prior to conducting any statistical analysis. p-values were based on results obtained from the transformed data. Model-based least square mean (LSM) estimates were obtained using the transformed data. Estimates and associated 95% confidence intervals (CI) were then back transformed via squaring (i.e., LSM2 ) to obtain LSM estimates in the original MDS units. For all variables and outcomes of interest, descriptive statistics (including means and standard deviations (SD) and/or 95% confidence intervals or frequencies and percentages) were calculated both overall and by professional group (i.e., nurse, physician, or other healthcare provider). For sub-groups with less than 5 responses, 95% confidence intervals were not constructed. One-way analysis of variance (ANOVA) models were used to compare the mean MDS among professional groups, and to compare the mean MDS within or between clinical specialty areas (e.g., ICU, step-down unit, etc.). If the results from the ANOVA indicated a significant difference among groups, the Tukey–Kramer multiple comparison procedure was used to determine which groups were significantly different while controlling the overall type-I error rate at 0.05.
Results Of 3041 individuals emailed the study survey, 1113 (36.6%) surveys were returned (Table 2). Response rates varied by profession; the largest return was from nurses (40.9%), and the smallest was from physicians (26.3%).
K. Trotochaud et al. Table 2
Responses by professional group. Overall
Physician Nurse
Other
Surveys sent n 3041 650 1765 626 Returned n (%) 1113 (36.6) 171 (26.3) 722 (40.9) 220 (35.1) Usable MDS ⁎ 869 (28.6) 133 (20.5) 577 (32.7) 159 (25.4) n (%) ⁎ MDS excluded responses with N 10% (or N 2) items missing.
The majority of respondents were female (88.6%), the mean age was 41.6 ± 11 years, and the mean years of experience were 15.9 ± 11 years. Respondents are described by profession in Table 1 and by clinical specialty/clinical area in Table 3. The mean (95% CI) MDS for all respondents was 50.2 (47.4–53.2), with physicians' mean MDS significantly higher than nurses' mean MDS (62.8 vs. 47.3; t(866) = 3.55, p = 0.001) (Table 4). All professional groups reported higher mean scores on level of disturbance than on frequency (2.11 vs. 0.94 respectively). However, physicians reported significantly higher frequency of morally distressing situations as compared to nurses (1.09 ± 0.48 vs. 0.90 ± 0.57; t(866) = 3.36; p = 0.002) and as compared to other providers (1.09 ± 0.48 vs. 0.93 ± 0.65; t(866) = 2.39; p = 0.002). There was no statistical difference in level of disturbance among professional groups. A direct relationship was found between high MDS and respondents stating that they had left or considered leaving a clinical position (Table 5). Greater than a third (n = 308, 35.7%) of respondents reported having left or considered leaving a clinical position because of moral distress. The average MDS was statistically higher for those who considered leaving their position but stayed and for those who actually left a clinical position (80.6 and 60.4, respectively) as compared to those who had never considered leaving their position (39.0, F(2,859) = 72.99; p b 0.001). Analysis by professional group also showed a statistically significant relationship between high moral distress and prior intent to leave a clinical position for all professional groups. When asked if they were considering leaving their current position, 8.7% (n = 74) of all respondents reported "Yes," and they were found to have the highest mean MDS (83.5), statistically higher than those who were not considering leaving now (47.1). Nurses and other providers who were currently thinking of leaving had statistically higher MDS than those who were not. No physician responded that he/she was considering leaving a current position. Mean MDS varied relative to the clinical specialty/area with which respondents identified (Table 6). The highest MDS (74.3) was reported by the total group of respondents who worked in ICUs. MDS varied between ICU professionals (other providers greater than nurses, nurses greater than physicians), but no statistically significant difference in mean MDS was found. However, some differences were found in MDS within professional groups based on clinical
Moral Distress in Pediatric Healthcare Providers Table 3
911
Respondents by clinical specialty/clinical area for each professional group. n (%) ⁎
Physician General pediatrics Emergency medicine Critical care medicine Hematology/Oncology Neonatology Cardiology Anesthesia Pulmonary Neurology Pediatric surgery Rehab Neurosurgery Orthopedics Otolaryngology Other
33 (25.2) 16 (12.2) 12 (9.2) 12 (9.2) 12 (9.2) 11 (8.4) 8 (6.1) 5 (3.8) 2 (1.5) 2 (1.5) 2 (1.5) 1 (0.8) 1 (0.8) 1 (0.8) 18 (13.7)
General care NICU PICU ED/Transport Surgical services Hematology/Oncology Specialty unit Cardiac ICU Technology-dependent ICU Ambulatory care Other
Nurse n (%) ⁎
Other n (%) ⁎
107 (17.6) 84 (13.8) 79 (13) 73 (12) 70 (11.5) 68 (11.2) 41 (6.7) 35 (5.7) 24 (3.9) 21 (3.4) 54 (8.9)
40 (24.2) 38 (23) 47 (28.5) 19 (11.5) 14 (8.5) 26 (15.8) 26 (15.8) 16 (9.7) 31 (18.8) 13 (7.9) 59 (35.8)
⁎ Percent may total greater than 100 as some providers reported working in multiple clinical areas.
specialty/area. For example, ICU nurses reported statistically higher mean MDS than nurses from all other clinical areas (p = 0 .004 for ICU vs. hematology/oncology and p b 0.001 for all other areas). The mean MDS for other providers working in ICU was higher than other providers from most of the other clinical areas, but it was only significantly different for other providers from hematology/oncology (76.2 vs. 22.3; p =0.005). For physicians, there were no significant differences in mean MDS based on their clinical specialty. Respondents rated morally distressing situations on frequency and level of disturbance using a scale of 0–4. The mean score for level of disturbance for all situations was 2.11 (range 1.34–2.54), and the mean score for frequency was 0.94 (range 0.28–1.8). By multiplying level of disturbance by frequency, a mean composite score was computed for each situation with an average mean composite score of 2.66 (range 0.46–5.37). Table 7 presents mean scores for frequency, level of disturbance and composite scores for the top 9 morally distressing situations for all professionals. Higher scores were reported for situations describing aggressive, inappropriate treatment.
Table 4
Discussion Moral distress was reported by nurses, physicians and other providers working in a variety of pediatric healthcare settings. In contrast to prior studies reporting higher moral distress in nurses (Hamric & Blackhall, 2007; Hamric et al., 2012; Houston et al., 2013), this study found that pediatric physicians reported significantly higher moral distress than pediatric nurses. When analysis focused only on responses from intensive care providers, the setting most frequently used for previously reported studies, ICU nurses and other
Moral distress scores by professional group.
Category Frequency Mean(SD) Level of Disturbance Mean(SD) Moral Distress Score c Mean(95% CI) a
Situations which described continuing care not in child's best interest, providing life-saving actions that only prolong death, and participating in care when child is hopelessly ill, ranked first, second and fifth respectively. Situations reflecting a lack of team collaboration including poor team communication and lack of provider continuity ranked third and fourth respectively. Other situations with high composite scores included pressure to consider unnecessary tests and treatments, watching others provide false hope, unsafe staffing levels and working with incompetent nurses or other providers.
Overall n = 869
Physician n = 133
Nurse n = 577
Other n = 159
p-value
0.94(± 0.58)
1.09(± 0.48)
0.90(± 0.57)
0.93(± 0.65)
0.004 a
2.11(± 1.11)
2.17(± 0.9)
2.11(± 1.12)
2.08(± 1.1)
0.796
50.2(47.4–53.2)
62.8(54.8–71.4)
47.3(43.9–50.8)
51.2(44.6–58.3)
0.002 b
Doctors had significantly higher frequencies of distressing events compared to nurses (p = 0.002) and other healthcare professionals (p = 0.045). Doctors had a significantly higher moral distress score compared to nurses (p = 0.001). c p-values were based on analysis of square-root transformed data. Model adjusted estimates have been back transformed (by squaring the data), to obtain mean estimates in the original units. b
912 Table 5
K. Trotochaud et al. Moral distress scores and intent to leave a position by professional group.
Response
Total Mean(95% CI) n
Physician Mean(95% CI) n
Nurse Mean(95% CI) n
Other Mean(95% CI) n
Question: Have you ever left or considered quitting a clinical position because of your moral distress with the way patient care was handled at your organization? No, never 39.0(36.1–42.0)554 55.8(49.2–62.9)94 35.5(32.0–39.2)360 37.5(30.9–44.7)100 Yes, but did not leave 80.6(73.8–87.7)213 81.8(68.2–96.7)32 76.3(68.1–85.1)140 94.9(78.5–113.0)41 Yes, left 60.4(51.8–69.7)95 77.7(49.0–113.0)6 60.8(50.7–71.8)72 53.1(34.9–74.0)17 p-value a b 0.001 0.003 b 0.001 b 0.001 Question: Are you considering leaving your position now? No 47.1(44.2–50.1)776 60.5(54.2–67.0)120 43.9(40.4–47.5)513 48.5(41.4–56.1)143 Yes 83.5(71.3–96.6)74 – 82.7(69.0–97.6)59 86.8(59.2–119.7)15 b 0.001 – b 0.001 0.035 p-value a n indicates number of participants with usable MDS who responded to the question. a p-values were based on analysis of square-root transformed data. Model adjusted estimates have been back transformed (by squaring the data), to obtain mean estimates in the original units.
providers were found to have slightly higher moral distress than physicians. The differences, however, in MDS for ICU professionals are not statistically significant. The clinical context or specialty/area may elicit differing levels of moral distress for some healthcare professionals. For physicians, moral distress appears to be less influenced by clinical specialty than for nurses and other providers. Nurses from ICU areas have statistically significant higher moral distress than nurses working in all other clinical areas. Other providers working in ICU areas have higher MDS than other providers in most other areas, but this difference was only statistically significant when compared to other providers in hematology/oncology (p = 0.005). As reported by Hamric and Blackhall (2007) and Hamric et al. (2012), a direct association is found between high moral distress and intent to leave one's clinical position. However the impact on turnover appears to be less in pediatric providers than what is reported for providers working in adult settings. More than a third (35.7%) of all respondents reported a prior intent to leave a position due to moral distress. This response is somewhat lower than two previous studies which included nurses largely caring for adult patients who indicated a prior intent to leave at rates of 45% and 49% respectively (Hamric & Blackhall, 2007; Hamric et al., 2012). Respondents stating they are considering leaving their current position included nurses (10.3%)
Table 6
and other professionals (9.5%). These percentages are lower than reported by Hamric et al. (2012), who found 20% of nurses and 11% of physicians reported considering leaving their current position. The finding of higher moral distress in pediatric providers working in ICUs is consistent with other studies that included PICU or NICU providers alone (Cavaliere et al., 2010; Janvier et al., 2007) and that compared nurses and/or physicians from various settings (Hamric & Blackhall, 2007; Hamric et al., 2012). Comparative studies looking at moral distress in providers working in other clinical areas outside of the ICU are limited. This study reports moral distress in other pediatric clinical settings, including hematology/oncology (45.2; 95% CI (37.2–53.8)) and emergency department (ED)/transport (48.6; 95% CI (40.4–57.6)). Although one previous study reported on moral distress in hematology/ oncology nurses (Lazzarin et al., 2012), no identified studies report on moral distress in emergency department providers. This study included a large number of respondents who work in pediatric general care, but it is difficult to know how their moral distress compares to others working in pediatric or adult general care settings, as no studies are found that report on moral distress in providers working in general care settings. The reasons for differences in the degree of moral distress experienced by providers in different clinical areas are unclear and would require further study.
Moral distress scores by healthcare profession and clinical specialty/area.
Clinical specialty/area
Overall Mean(95% CI) n
Physician Mean(95% CI) n
Nurse Mean(95% CI) n
Other Mean(95% CI) n
ICU Step-down units Hematology/Oncology General care Surgical service ED/Transport Ambulatory care
74.3(68.8–80.0)286 42.6(32.4–54.3)43 45.2(37.2–53.8)79 40.0(34.4–46.1)140 27.4(20.9–34.8)69 48.6(40.4–57.6)82 20.5(10.5–33.9)18
71.1(58.5–84.8)30 59.0(35.6–88.3)6 42.0(27.3–60.0)11 57.9(46.9–70.0)31 71.6(50.9–95.9)10 80.2(60.7–102.5)13 –
74.2(67.6–81.1)192 36.7(26.0–49.3)32 50.0(40.6–60.4)59 34.3(28.0–41.2)93 20.0(14.0–27.0)56 43.0(34.5–52.5)63 20.2(9.6–34.8)15
76.2(63.9–89.5)64 66.8(30.8–116.6)5 22.3(7.7–44.7)9 43.0(25.9–64.4)16 77.1–3 49.0(13.1–108.0)6 22.1–3
n indicates number of participants with usable MDS who responded to the question.
Moral Distress in Pediatric Healthcare Providers Table 7
913
Top 9 morally distressing situations.
Situation
Composite ⁎ mean (rank)
Follow the family's wishes to continue life support even though I believe it is not in the best interest of the child. Initiate extensive live-saving actions when I think they only prolong death. Witness diminished patient care quality due to poor team communication. Watch patient care suffer because of a lack of provider continuity. Continue to participate in care for a hopelessly ill child who is being sustained on a ventilator, when no one will make a decision to withdraw support. Feel pressure to order (or carry out the physician's order for) what I consider to be unnecessary tests and treatments. Witness other healthcare providers giving "false hope" to parents. Work with levels of nurse or other care provider staffing that is considered unsafe. Work with nurses or other providers who are not as competent as the child's care requires.
5.37 (1) 4.86 4.24 4.13 4.09
(2) (3) (4) (5)
Level of disturbance mean (rank) 2.3 (7) 2.32 (6) 2.54 (1) 2.38 (3) 2.25 (8)
Frequency mean (rank) 1.8 (1) 1.63 1.39 1.39 1.32
(2) (4) (5) (6)
3.64 (6)
1.9 (16)
1.47 (3)
3.33 (7) 3.22 (8) 3.21 (9)
2.05 (11) 2.45 (2) 2.33 (4)
1.2 (7) 1 (9) 1.07 (8)
⁎ Composite score is the score for level of disturbance by score for frequency.
For situations presented in the survey, higher scores for frequency generally correlated with higher scores for level of disturbance, resulting in higher composite scores. As in other studies, the situations that describe aggressive treatment at the end of life or treatments believed not to be medically appropriate resulted in high mean composite scores (Allen et al., 2013; Hamric & Blackhall, 2007; Hamric et al., 2012). These situations present as more morally distressing because they are reported as occurring more frequently than other situations. Lack of team collaboration, while occurring less frequently, was also found to be very disturbing. Although different professionals ranked individual situations differently, all professions ranked the previously described situations in the top tier of morally distressing situations.
Limitations Participants in this study came from a single pediatric healthcare organization, so the results may not reflect moral distress for pediatric providers in general. Since non-respondents were not sampled, no comparisons can be made to providers who did not choose to participate. Additionally, because participants self-selected to participate in the study, there could be selection bias in the sample. Although surveys were sent to individual e-mail addresses, there was no way to confirm the targeted individuals actually completed the surveys. Although the total sample was large, as groupings were analyzed by provider group and clinical specialty/area, the numbers became smaller, making it more difficult to interpret the responses for smaller groupings.
Clinical Implications Moral distress experienced by pediatric healthcare providers influences not only job satisfaction, emotional outlook and physical well-being, but is also linked to job retention and staff turnover. Because optimal healthcare for children requires an adequate number of trained pediatric professionals, factors that result in loss of experienced healthcare providers are important to address. The correlation between moral distress
and pediatric provider turnover cannot be understated. More fully understanding the experience of the pediatric professional requires knowledge about provider moral distress and its contributors, and identifying the ways it can be addressed and mitigated starts with knowing who is most likely to experience moral distress. Although moral distress in ICU staff is supported by numerous studies, nurses are not the only pediatric providers affected as evidenced by the degree of moral distress reported by pediatric physicians. When considering interventions to address moral distress in pediatric setting, it is clear that physicians, nurses and other healthcare providers all should be included in these interventions. The clinical specialty/area also matters. Although professionals in intensive care settings are more vulnerable to moral distress, professionals in many pediatric clinical settings report experiencing moral distress. A better understanding about moral distress in non-ICU healthcare providers is needed. Very little is understood about the experience of moral distress in clinical settings like the emergency department or general care. Certain clinical scenarios are more often associated with provider moral distress than others, for example, when providers are asked to continued aggressive, end-of-life care believed not to be appropriate and when providers are faced with lack of team collaboration resulting from poor team communication and lack of provider continuity. In the current healthcare environment, it is unlikely that these types of situations will be eliminated, making it imperative that moral distress be recognized and understood so it can be appropriately addressed. In conclusion, the purpose of this study was to more fully assess the degree of moral distress experienced by different pediatric providers in a variety of clinical settings, including moral distress experienced outside of ICU settings. Using the results of this study, pediatric organizations can begin to develop context-specific interventions to address provider moral distress. Strategies may be created that help providers recognize morally distressing situations when they experience them, offer
914 providers proactive and in-the-moment tools to address these situations, and support providers through morally challenging and unalterable situations when there is no way to change the course of action.
Funding Source Dudley L. Moore Nursing and Allied Health Research Fund.
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Moral Distress in Pediatric Healthcare Providers1 Karen Trotochaud MN, MA, RN a,⁎, Joyce Ramsey Coleman MBA, MS, RN, NEA-BC a,2 , Nicolas Krawiecki MD a,b , Courtney McCracken PhD b a
Children's Healthcare of Atlanta, Atlanta, GA Emory University, Atlanta, GA
b
Received 6 January 2014; revised 11 March 2015; accepted 12 March 2015
Key words: Moral distress; Pediatric providers; Intensive care
Pediatric providers across professions and clinical settings experience moral distress. Higher moral distress correlates with intent to leave for all professionals. Physicians as professional group had the highest moral distress. Intensive care nurses had the highest moral distress for nurses. While all providers describe distressing scenarios as disturbing, physicians report situations as occurring more frequently. The most distressing situations include requests for aggressive treatments not in child's best interest, poor team communication and lack of provider continuity. Understanding moral distress as experienced by all pediatric providers is needed to create interventions with a goal of reducing provider turnover. © 2015 Elsevier Inc. All rights reserved.
SAFE, HIGH QUALITY pediatric healthcare cannot exist without the retention of a prepared and experienced provider workforce. The growing problem of healthcare provider shortages, especially nurse shortages, is a national priority as identified in Institute of Medicine reports on the state of nursing (Finkelman & Kenner, 2012). The phenomenon of moral distress has been linked to job retention, a critical work force issue for healthcare organizations (Burston & Tuckett, 2012). The focus of this study is assessment of the degree of moral distress experienced by pediatric healthcare providers including nurses, physicians and other healthcare providers and the relationship of moral distress to healthcare provider job retention. Moral distress, defined as distress that occurs when constraints make it nearly impossible to pursue the right course of action (Jameton, 1984), is identified as a significant factor 1
affecting nurse satisfaction and retention (Allen et al., 2013; Houston et al., 2013; Pauley, Varcoe, & Storch, 2012). Wilkerson's (1987/88) Moral Distress Model (MDM) describes moral distress as a negative feeling state that results when an individual decides that an action is morally right but does not follow through with this action. In this model, the degree of distress experienced is significantly affected by the frequency of cases encountered and the ability of one to effectively cope with these encounters. Nursing turnover is a negative outcome of frequent encounters that are felt as very distressing. Root causes of moral distress can be internal to the caregiver (perceived powerlessness, lack of knowledge of alternatives) or external factors (poor staffing, limited administrative support, provider incompetence). Constraints can be embedded in the clinical situations themselves, like requests for futile or
Previous Presentations: Poster Presentations 1. 4th Annual Nursing Research Symposium, Children's Healthcare of Atlanta Atlanta, Georgia; May 8, 2013. 2. American Society for Bioethics and the Humanities 15th Annual Conference Atlanta, Georgia; October 24–27, 2013. ⁎ Corresponding author: Karen Trotochaud MN, MA, RN. E-mail address: [email protected]. 2 Present address: Texas Children’s Hospital, Houston, Texas. http://dx.doi.org/10.1016/j.pedn.2015.03.001 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Moral Distress in Pediatric Healthcare Providers Table 1 Physician Attending Resident Fellow Other Missing
909
Respondents by position for each professional group. n (%) 98 21 10 1 3
(73.7) (15.8) (7.5) (0.8) (2.3)
Nurse Novice (b 1 year) Colleague (N 1 year) Resource Leader (masters) Asst. nurse manager Clinical educator Nurse practitioner Other Missing
inappropriately aggressive treatment, inadequate informed consent, or witnessing false hope (Hamric, 2012). The impact of moral distress on providers includes emotional responses (anger, frustration, guilt) and physical disorders (headache, sleep dysfunctions). It can affect social relationships and contribute to avoidance behaviors in professional interactions (Gutierrez, 2005). An ongoing concern of healthcare organizations is the impact moral distress has on intent to leave one's clinical position. Moral distress contributes to nursing turnover and is directly correlated to nurses' intent to leave their clinical positions (Cavaliere, Daly, Dowling, & Montgomery, 2010; Corley, 1995; Hamric, Borchers, & Epstein, 2012). Although largely studied in providers who care for adult patients, moral distress is described in some pediatric nurses. Grief and moral distress are identified in pediatric intensive care unit (PICU) nurses working with children at the end of life (Davies et al., 1996; Lee & Dupree, 2008) and in neonatal intensive care unit (NICU) nurses related to resuscitation and outcome of premature infants (Janvier, Nadeau, Deschênes, Couture, & Barrington, 2007). When compared, nurses from adult intensive care units (ICUs) report somewhat higher moral distress than nurses from PICUs (Lawrence, 2011). In one study of pediatric oncology/hematology nurses, over 50% of the nurses report thinking about leaving their current clinical setting due to psychological reasons and moral distress (Lazzarin, Biondi, & Di Mauro, 2012). Recent reports identify moral distress in professionals other than nurses. Significant moral distress is identified in pediatric residents (Hilliard, Harrison, & Madden, 2007). Of physicians and nurses working in adult and pediatric ICUs, nurses are found to have higher moral distress compared to physicians (Hamric & Blackhall, 2007; Hamric et al., 2012). Two recent studies comparing moral distress in a variety of professionals working in differing clinical settings report moderate to high levels of moral distress in all disciplines with nurses reporting the highest overall level of distress (Allen et al., 2013; Houston et al., 2013). Using Wilkerson's (1987/88) MDM as the conceptual framework, this study seeks to better understand moral distress experienced by all pediatric providers. The objectives of this
n (%) 14 (2.4) 241 (41.8) 204 (35.4) 11 (1.9) 64 (11.1) 3 (0.5) 23 (4) 4 (0.7) 13 (2.3)
Other Respiratory therapist Social worker Physical therapist Speech pathologist Child life specialist Interpreter/Translator Occupational therapist Physician's assistant Chaplain School teacher Paramedic Other Missing
n (%) 43 23 21 13 12 9 5 5 4 3 1 14 6
(27) (14.5) (13.2) (8.2) (7.5) (5.7) (3.1) (3.1) (2.5) (1.9) (0.6) (8.8) (3.8)
study are: (1) to determine the degree of moral distress experienced by pediatric providers from different professional groups and working in different clinical settings; (2) to describe the relationship of moral distress to pediatric provider intent to leave; and (3) to identify specific situations more likely to be associated with pediatric provider moral distress.
Methods A descriptive study on moral distress in pediatric providers was conducted in April and May 2012. The setting was a large pediatric health system in the southeast that includes three children's hospitals with 60 pediatric specialties. A convenience sample included all registered nurses providing direct patient care (n = 1765); attending physicians with admitting privileges, subspecialty fellows, and pediatric residents (n =650); and other healthcare professionals including respiratory therapists, social workers, physical therapist, and other healthcare providers (n = 626). (Table 1 shows a full list of other providers by profession) The survey was sent via e-mail and providers were invited to complete the survey through a direct link to SurveyMonkey®. Participants were given 6 weeks to complete the survey with reminders sent to non-respondents at 2 and 4 weeks. The survey included demographic questions, two questions about intent to leave one's position, and the Moral Distress Scale-Revised (MDS-R©) (Hamric et al., 2012). This scale included 21 statements describing situations known to cause moral distress in clinical practice. Respondents rated each situation on two dimensions: (1) how frequently they experience it (0 = never to 4 = very frequently) and (2) how disturbing it is or would be for them (0 = none to 4 = great extent). Composite scores for each situation (range 0–16) were computed, and an overall moral distress score or MDS (range 0–336)) was calculated. An overall respondent MDS could be calculated only if greater than 90% of individual situation scores were completed. The Moral Distress Scale originally developed and validated by Corley (1995) in critical care nurses included 38 morally distressing situations rated on a 7-point Likert
910 scale, and it achieved internal reliability determined using Cronbach's alpha. Hamric and Blackhall (2007) revised this scale reducing it to include 21 situations using a Likert scale of 0–4 rating frequency and level of disturbance for each situation. Cronbach's alpha internal reliability was conducted using both nurses and physicians from adult and pediatric intensive care settings. Hamric et al. (2012) later adapted and tested a revised scale, MDS-R© , for use in multiple health care settings and with different professionals including physicians, nurses and other professionals with versions for adult and pediatric providers. An inter-rater agreement of 88% was achieved, and reliability using Cronbach's alpha of 0.88 for all participants was obtained using nurse and physician populations. Additional information on the validation of the MDS-R© is reported by Hamric et al. (2012). Permission was granted from Hamric for use of the scale in this study. Approval from the institutional review board was obtained, and a waiver of written consent was obtained. Participant responses were submitted anonymously directly to SurveyMonkey®. To maintain confidentiality no names or identifying information for respondents were collected.
Statistical Analysis All statistical analyses were conducted using SAS 9.2 for Windows (Cary, NC). Statistical significance was assessed at the 0.05 level. The primary outcome variable, MDS, was not normally distributed; therefore, a square-root transformation was applied to the original MDS prior to conducting any statistical analysis. p-values were based on results obtained from the transformed data. Model-based least square mean (LSM) estimates were obtained using the transformed data. Estimates and associated 95% confidence intervals (CI) were then back transformed via squaring (i.e., LSM2 ) to obtain LSM estimates in the original MDS units. For all variables and outcomes of interest, descriptive statistics (including means and standard deviations (SD) and/or 95% confidence intervals or frequencies and percentages) were calculated both overall and by professional group (i.e., nurse, physician, or other healthcare provider). For sub-groups with less than 5 responses, 95% confidence intervals were not constructed. One-way analysis of variance (ANOVA) models were used to compare the mean MDS among professional groups, and to compare the mean MDS within or between clinical specialty areas (e.g., ICU, step-down unit, etc.). If the results from the ANOVA indicated a significant difference among groups, the Tukey–Kramer multiple comparison procedure was used to determine which groups were significantly different while controlling the overall type-I error rate at 0.05.
Results Of 3041 individuals emailed the study survey, 1113 (36.6%) surveys were returned (Table 2). Response rates varied by profession; the largest return was from nurses (40.9%), and the smallest was from physicians (26.3%).
K. Trotochaud et al. Table 2
Responses by professional group. Overall
Physician Nurse
Other
Surveys sent n 3041 650 1765 626 Returned n (%) 1113 (36.6) 171 (26.3) 722 (40.9) 220 (35.1) Usable MDS ⁎ 869 (28.6) 133 (20.5) 577 (32.7) 159 (25.4) n (%) ⁎ MDS excluded responses with N 10% (or N 2) items missing.
The majority of respondents were female (88.6%), the mean age was 41.6 ± 11 years, and the mean years of experience were 15.9 ± 11 years. Respondents are described by profession in Table 1 and by clinical specialty/clinical area in Table 3. The mean (95% CI) MDS for all respondents was 50.2 (47.4–53.2), with physicians' mean MDS significantly higher than nurses' mean MDS (62.8 vs. 47.3; t(866) = 3.55, p = 0.001) (Table 4). All professional groups reported higher mean scores on level of disturbance than on frequency (2.11 vs. 0.94 respectively). However, physicians reported significantly higher frequency of morally distressing situations as compared to nurses (1.09 ± 0.48 vs. 0.90 ± 0.57; t(866) = 3.36; p = 0.002) and as compared to other providers (1.09 ± 0.48 vs. 0.93 ± 0.65; t(866) = 2.39; p = 0.002). There was no statistical difference in level of disturbance among professional groups. A direct relationship was found between high MDS and respondents stating that they had left or considered leaving a clinical position (Table 5). Greater than a third (n = 308, 35.7%) of respondents reported having left or considered leaving a clinical position because of moral distress. The average MDS was statistically higher for those who considered leaving their position but stayed and for those who actually left a clinical position (80.6 and 60.4, respectively) as compared to those who had never considered leaving their position (39.0, F(2,859) = 72.99; p b 0.001). Analysis by professional group also showed a statistically significant relationship between high moral distress and prior intent to leave a clinical position for all professional groups. When asked if they were considering leaving their current position, 8.7% (n = 74) of all respondents reported "Yes," and they were found to have the highest mean MDS (83.5), statistically higher than those who were not considering leaving now (47.1). Nurses and other providers who were currently thinking of leaving had statistically higher MDS than those who were not. No physician responded that he/she was considering leaving a current position. Mean MDS varied relative to the clinical specialty/area with which respondents identified (Table 6). The highest MDS (74.3) was reported by the total group of respondents who worked in ICUs. MDS varied between ICU professionals (other providers greater than nurses, nurses greater than physicians), but no statistically significant difference in mean MDS was found. However, some differences were found in MDS within professional groups based on clinical
Moral Distress in Pediatric Healthcare Providers Table 3
911
Respondents by clinical specialty/clinical area for each professional group. n (%) ⁎
Physician General pediatrics Emergency medicine Critical care medicine Hematology/Oncology Neonatology Cardiology Anesthesia Pulmonary Neurology Pediatric surgery Rehab Neurosurgery Orthopedics Otolaryngology Other
33 (25.2) 16 (12.2) 12 (9.2) 12 (9.2) 12 (9.2) 11 (8.4) 8 (6.1) 5 (3.8) 2 (1.5) 2 (1.5) 2 (1.5) 1 (0.8) 1 (0.8) 1 (0.8) 18 (13.7)
General care NICU PICU ED/Transport Surgical services Hematology/Oncology Specialty unit Cardiac ICU Technology-dependent ICU Ambulatory care Other
Nurse n (%) ⁎
Other n (%) ⁎
107 (17.6) 84 (13.8) 79 (13) 73 (12) 70 (11.5) 68 (11.2) 41 (6.7) 35 (5.7) 24 (3.9) 21 (3.4) 54 (8.9)
40 (24.2) 38 (23) 47 (28.5) 19 (11.5) 14 (8.5) 26 (15.8) 26 (15.8) 16 (9.7) 31 (18.8) 13 (7.9) 59 (35.8)
⁎ Percent may total greater than 100 as some providers reported working in multiple clinical areas.
specialty/area. For example, ICU nurses reported statistically higher mean MDS than nurses from all other clinical areas (p = 0 .004 for ICU vs. hematology/oncology and p b 0.001 for all other areas). The mean MDS for other providers working in ICU was higher than other providers from most of the other clinical areas, but it was only significantly different for other providers from hematology/oncology (76.2 vs. 22.3; p =0.005). For physicians, there were no significant differences in mean MDS based on their clinical specialty. Respondents rated morally distressing situations on frequency and level of disturbance using a scale of 0–4. The mean score for level of disturbance for all situations was 2.11 (range 1.34–2.54), and the mean score for frequency was 0.94 (range 0.28–1.8). By multiplying level of disturbance by frequency, a mean composite score was computed for each situation with an average mean composite score of 2.66 (range 0.46–5.37). Table 7 presents mean scores for frequency, level of disturbance and composite scores for the top 9 morally distressing situations for all professionals. Higher scores were reported for situations describing aggressive, inappropriate treatment.
Table 4
Discussion Moral distress was reported by nurses, physicians and other providers working in a variety of pediatric healthcare settings. In contrast to prior studies reporting higher moral distress in nurses (Hamric & Blackhall, 2007; Hamric et al., 2012; Houston et al., 2013), this study found that pediatric physicians reported significantly higher moral distress than pediatric nurses. When analysis focused only on responses from intensive care providers, the setting most frequently used for previously reported studies, ICU nurses and other
Moral distress scores by professional group.
Category Frequency Mean(SD) Level of Disturbance Mean(SD) Moral Distress Score c Mean(95% CI) a
Situations which described continuing care not in child's best interest, providing life-saving actions that only prolong death, and participating in care when child is hopelessly ill, ranked first, second and fifth respectively. Situations reflecting a lack of team collaboration including poor team communication and lack of provider continuity ranked third and fourth respectively. Other situations with high composite scores included pressure to consider unnecessary tests and treatments, watching others provide false hope, unsafe staffing levels and working with incompetent nurses or other providers.
Overall n = 869
Physician n = 133
Nurse n = 577
Other n = 159
p-value
0.94(± 0.58)
1.09(± 0.48)
0.90(± 0.57)
0.93(± 0.65)
0.004 a
2.11(± 1.11)
2.17(± 0.9)
2.11(± 1.12)
2.08(± 1.1)
0.796
50.2(47.4–53.2)
62.8(54.8–71.4)
47.3(43.9–50.8)
51.2(44.6–58.3)
0.002 b
Doctors had significantly higher frequencies of distressing events compared to nurses (p = 0.002) and other healthcare professionals (p = 0.045). Doctors had a significantly higher moral distress score compared to nurses (p = 0.001). c p-values were based on analysis of square-root transformed data. Model adjusted estimates have been back transformed (by squaring the data), to obtain mean estimates in the original units. b
912 Table 5
K. Trotochaud et al. Moral distress scores and intent to leave a position by professional group.
Response
Total Mean(95% CI) n
Physician Mean(95% CI) n
Nurse Mean(95% CI) n
Other Mean(95% CI) n
Question: Have you ever left or considered quitting a clinical position because of your moral distress with the way patient care was handled at your organization? No, never 39.0(36.1–42.0)554 55.8(49.2–62.9)94 35.5(32.0–39.2)360 37.5(30.9–44.7)100 Yes, but did not leave 80.6(73.8–87.7)213 81.8(68.2–96.7)32 76.3(68.1–85.1)140 94.9(78.5–113.0)41 Yes, left 60.4(51.8–69.7)95 77.7(49.0–113.0)6 60.8(50.7–71.8)72 53.1(34.9–74.0)17 p-value a b 0.001 0.003 b 0.001 b 0.001 Question: Are you considering leaving your position now? No 47.1(44.2–50.1)776 60.5(54.2–67.0)120 43.9(40.4–47.5)513 48.5(41.4–56.1)143 Yes 83.5(71.3–96.6)74 – 82.7(69.0–97.6)59 86.8(59.2–119.7)15 b 0.001 – b 0.001 0.035 p-value a n indicates number of participants with usable MDS who responded to the question. a p-values were based on analysis of square-root transformed data. Model adjusted estimates have been back transformed (by squaring the data), to obtain mean estimates in the original units.
providers were found to have slightly higher moral distress than physicians. The differences, however, in MDS for ICU professionals are not statistically significant. The clinical context or specialty/area may elicit differing levels of moral distress for some healthcare professionals. For physicians, moral distress appears to be less influenced by clinical specialty than for nurses and other providers. Nurses from ICU areas have statistically significant higher moral distress than nurses working in all other clinical areas. Other providers working in ICU areas have higher MDS than other providers in most other areas, but this difference was only statistically significant when compared to other providers in hematology/oncology (p = 0.005). As reported by Hamric and Blackhall (2007) and Hamric et al. (2012), a direct association is found between high moral distress and intent to leave one's clinical position. However the impact on turnover appears to be less in pediatric providers than what is reported for providers working in adult settings. More than a third (35.7%) of all respondents reported a prior intent to leave a position due to moral distress. This response is somewhat lower than two previous studies which included nurses largely caring for adult patients who indicated a prior intent to leave at rates of 45% and 49% respectively (Hamric & Blackhall, 2007; Hamric et al., 2012). Respondents stating they are considering leaving their current position included nurses (10.3%)
Table 6
and other professionals (9.5%). These percentages are lower than reported by Hamric et al. (2012), who found 20% of nurses and 11% of physicians reported considering leaving their current position. The finding of higher moral distress in pediatric providers working in ICUs is consistent with other studies that included PICU or NICU providers alone (Cavaliere et al., 2010; Janvier et al., 2007) and that compared nurses and/or physicians from various settings (Hamric & Blackhall, 2007; Hamric et al., 2012). Comparative studies looking at moral distress in providers working in other clinical areas outside of the ICU are limited. This study reports moral distress in other pediatric clinical settings, including hematology/oncology (45.2; 95% CI (37.2–53.8)) and emergency department (ED)/transport (48.6; 95% CI (40.4–57.6)). Although one previous study reported on moral distress in hematology/ oncology nurses (Lazzarin et al., 2012), no identified studies report on moral distress in emergency department providers. This study included a large number of respondents who work in pediatric general care, but it is difficult to know how their moral distress compares to others working in pediatric or adult general care settings, as no studies are found that report on moral distress in providers working in general care settings. The reasons for differences in the degree of moral distress experienced by providers in different clinical areas are unclear and would require further study.
Moral distress scores by healthcare profession and clinical specialty/area.
Clinical specialty/area
Overall Mean(95% CI) n
Physician Mean(95% CI) n
Nurse Mean(95% CI) n
Other Mean(95% CI) n
ICU Step-down units Hematology/Oncology General care Surgical service ED/Transport Ambulatory care
74.3(68.8–80.0)286 42.6(32.4–54.3)43 45.2(37.2–53.8)79 40.0(34.4–46.1)140 27.4(20.9–34.8)69 48.6(40.4–57.6)82 20.5(10.5–33.9)18
71.1(58.5–84.8)30 59.0(35.6–88.3)6 42.0(27.3–60.0)11 57.9(46.9–70.0)31 71.6(50.9–95.9)10 80.2(60.7–102.5)13 –
74.2(67.6–81.1)192 36.7(26.0–49.3)32 50.0(40.6–60.4)59 34.3(28.0–41.2)93 20.0(14.0–27.0)56 43.0(34.5–52.5)63 20.2(9.6–34.8)15
76.2(63.9–89.5)64 66.8(30.8–116.6)5 22.3(7.7–44.7)9 43.0(25.9–64.4)16 77.1–3 49.0(13.1–108.0)6 22.1–3
n indicates number of participants with usable MDS who responded to the question.
Moral Distress in Pediatric Healthcare Providers Table 7
913
Top 9 morally distressing situations.
Situation
Composite ⁎ mean (rank)
Follow the family's wishes to continue life support even though I believe it is not in the best interest of the child. Initiate extensive live-saving actions when I think they only prolong death. Witness diminished patient care quality due to poor team communication. Watch patient care suffer because of a lack of provider continuity. Continue to participate in care for a hopelessly ill child who is being sustained on a ventilator, when no one will make a decision to withdraw support. Feel pressure to order (or carry out the physician's order for) what I consider to be unnecessary tests and treatments. Witness other healthcare providers giving "false hope" to parents. Work with levels of nurse or other care provider staffing that is considered unsafe. Work with nurses or other providers who are not as competent as the child's care requires.
5.37 (1) 4.86 4.24 4.13 4.09
(2) (3) (4) (5)
Level of disturbance mean (rank) 2.3 (7) 2.32 (6) 2.54 (1) 2.38 (3) 2.25 (8)
Frequency mean (rank) 1.8 (1) 1.63 1.39 1.39 1.32
(2) (4) (5) (6)
3.64 (6)
1.9 (16)
1.47 (3)
3.33 (7) 3.22 (8) 3.21 (9)
2.05 (11) 2.45 (2) 2.33 (4)
1.2 (7) 1 (9) 1.07 (8)
⁎ Composite score is the score for level of disturbance by score for frequency.
For situations presented in the survey, higher scores for frequency generally correlated with higher scores for level of disturbance, resulting in higher composite scores. As in other studies, the situations that describe aggressive treatment at the end of life or treatments believed not to be medically appropriate resulted in high mean composite scores (Allen et al., 2013; Hamric & Blackhall, 2007; Hamric et al., 2012). These situations present as more morally distressing because they are reported as occurring more frequently than other situations. Lack of team collaboration, while occurring less frequently, was also found to be very disturbing. Although different professionals ranked individual situations differently, all professions ranked the previously described situations in the top tier of morally distressing situations.
Limitations Participants in this study came from a single pediatric healthcare organization, so the results may not reflect moral distress for pediatric providers in general. Since non-respondents were not sampled, no comparisons can be made to providers who did not choose to participate. Additionally, because participants self-selected to participate in the study, there could be selection bias in the sample. Although surveys were sent to individual e-mail addresses, there was no way to confirm the targeted individuals actually completed the surveys. Although the total sample was large, as groupings were analyzed by provider group and clinical specialty/area, the numbers became smaller, making it more difficult to interpret the responses for smaller groupings.
Clinical Implications Moral distress experienced by pediatric healthcare providers influences not only job satisfaction, emotional outlook and physical well-being, but is also linked to job retention and staff turnover. Because optimal healthcare for children requires an adequate number of trained pediatric professionals, factors that result in loss of experienced healthcare providers are important to address. The correlation between moral distress
and pediatric provider turnover cannot be understated. More fully understanding the experience of the pediatric professional requires knowledge about provider moral distress and its contributors, and identifying the ways it can be addressed and mitigated starts with knowing who is most likely to experience moral distress. Although moral distress in ICU staff is supported by numerous studies, nurses are not the only pediatric providers affected as evidenced by the degree of moral distress reported by pediatric physicians. When considering interventions to address moral distress in pediatric setting, it is clear that physicians, nurses and other healthcare providers all should be included in these interventions. The clinical specialty/area also matters. Although professionals in intensive care settings are more vulnerable to moral distress, professionals in many pediatric clinical settings report experiencing moral distress. A better understanding about moral distress in non-ICU healthcare providers is needed. Very little is understood about the experience of moral distress in clinical settings like the emergency department or general care. Certain clinical scenarios are more often associated with provider moral distress than others, for example, when providers are asked to continued aggressive, end-of-life care believed not to be appropriate and when providers are faced with lack of team collaboration resulting from poor team communication and lack of provider continuity. In the current healthcare environment, it is unlikely that these types of situations will be eliminated, making it imperative that moral distress be recognized and understood so it can be appropriately addressed. In conclusion, the purpose of this study was to more fully assess the degree of moral distress experienced by different pediatric providers in a variety of clinical settings, including moral distress experienced outside of ICU settings. Using the results of this study, pediatric organizations can begin to develop context-specific interventions to address provider moral distress. Strategies may be created that help providers recognize morally distressing situations when they experience them, offer
914 providers proactive and in-the-moment tools to address these situations, and support providers through morally challenging and unalterable situations when there is no way to change the course of action.
Funding Source Dudley L. Moore Nursing and Allied Health Research Fund.
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