Hefferman et al14 | USA | NICU staff
| 98 24 67 3 1 3 | Two qualitative surveys—convenience sample—spaced two months apart |
▸ To explore ethical dilemmas healthcare professionals faced and describe the impact, if any, such dilemmas had on their care or sense of self as healthcare providers ▸ Explore whether dilemmas elicit moral distress
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▸ Expressed moral distress raises more questions regarding resuscitation and treatment of infants born at ‘edge of viability’ ▸ Difficult dilemmas can bring about moral distress in healthcare professionals
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▸ Advancing technology ▸ Disproportionate care ▸ Medical hierarchy ▸ Decision-making
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▸ Survey sought ‘ethical dilemmas’ and the term was used interchangeably with moral distress ▸ Initial survey results made available to all staff prior to second survey ▸ Unknown response rate ▸ Unclear aims and methodology
| Those experiencing moral distress need to ‘be given a voice’ in the decision-making process |
Solomon et al11 | USA | Multidisciplinary paediatric staff in PICUs, medical, surgical or haematology/oncology units. Overall response rate 64% (54%–71% across sites)
▸ attending physicians
‘house officers’ nurses
| 781 209 25 116 456 267 |
▸ Quantitative questionnaire, population based ▸ Based on the Decisions Near the End of Life Institutional profile
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▸ To determine the extent to which a variety of healthcare professionals are in agreement with one another and with published ethical recommendations regarding the withholding and withdrawing of life-sustaining therapies and the role of parents in end-of-life decision-making ▸ To determine the extent to which healthcare professionals are concerned with problems of overtreatment
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▸ 80% of critical care physicians and 69% of critical care nurses reported acting against their conscience and ‘saving children who should not be saved’ ▸ 56% of critical care physicians and 32% of critical care nurses reported feeling that sometimes the treatment they offer children is overly burdensome
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▸ Conscience ▸ Burdensome care
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▸ More research on regard for the dead-donor rule ▸ More ethics education required ▸ More interdisciplinary and cross-subspecialty discussion of inherently complex and stressful paediatric end-of-life cases
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Janvier et al12 | Canada |
| 115 164 | Quantitative questionnaire, population based | To determine the frequency of ethical confrontations (using a moral distress definition explicitly described) and factors associated with increased frequency |
▸ Moral distress was experienced by 35% of nurses and 19% of residents ▸ Ethical confrontations are influenced by knowledge levels regarding outcomes of preterm infants (more moral distress when inaccurate knowledge) ▸ Ethical confrontations are more frequent where there is more cultural diversity.
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▸ Ethical confrontations ▸ Knowledge
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▸ Attending physicians not included ▸ Limited definition of ethical confrontations ▸ Only examined overtreatment and not undertreatment component of moral distress
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▸ Ethical confrontation may be unavoidable and beneficial when approached critically and discussed as a team ▸ Further studies to equip trainees and healthcare workers with the tools to examine confrontations, to learn from, and profit from them
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Catlin et al27 | USA | Critical care nurses
| 66 53 13 |
| To verify the clinical use of their concept of conscientious objection in cases of moral distress | Analysis of conscientious objection use in neonatal and paediatric nursing care |
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| To direct research towards interventions ‘that will prevent futile care as well as to protect and defend nurses from the pain of powerless and participation in such cases that appear to harming patients’ |
Lee and Dupree18 | USA | PICU staff (multidisciplinary)
(Single centre PICU) | 29 |
| To describe the experiences of PICU healthcare professionals caring for a child who dies and to determine whether healthcare professionals experienced moral distress | Grief was more prominent as a response than moral distress |
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▸ Interviewed until saturation of themes but small sample of 8 patients ▸ Enrolled after deaths; ?appropriate timing ▸ Greater moral distress associated with patients that are thought to have received disproportionate care
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Cavaliere et al4 | USA | RNs n=196 (48% response rate)
(2 level III NICUs) | 94 |
▸ Quantitative, descriptive, correlational study, convenience sample ▸ MDSNPV (Moral distress scale—paediatric version)
| To describe moral distress of RNs working in NICUs and to identify the situations associated with their moral distress |
▸ Moral distress, as identified by MDS was infrequent and low intensity ▸ Mean intensity scores for top 10 distressing situations ranged from 1.71 to 3.18 ▸ Following family wishes to continue when not in child's best interest caused greatest moral distress
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McGibbon et al15 | Canada | PICU nurses
(Paediatric hospital) | 23 |
▸ Qualitative study, theoretical sampling ▸ Institutional ethnography ▸ In-depth interviews, participant observation and focus groups
| To reformulate the nature of stress in nursing with attention to contextual aspects of nursing |
▸ Nurses’ stress is very much related to the social relations of power which may lead to moral distress ▸ Formulations of nursing stress (including moral distress) must reflect the dynamics between the nurse, the environment and surrounding relationships and hierarchies
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▸ Emotional distress ▸ Burden of responsibility ▸ Constancy of presence ▸ Bodily caring? ▸ Being mothers, sisters, daughters and aunts
| Convenience sample rather than reaching saturation of themes | Conceptualisations of nurse’ stress including occupational, moral distress and traumatisation require further contexualisation |
Lawrence21 | USA | RNs n=98 (14% response rate)
| 28 7 11 10 |
▸ Quantitative, descriptive, correlation study, convenience sample ▸ Demographic Data Collection Tool ▸ UWES ▸ MDS (in part) ▸ CRPQ ▸ RRQ in part
| To examine how nurses’ moral distress, education level and CRP related to work engagement |
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▸ Education ▸ Workplace engagement ▸ Moral distress ▸ CRP
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▸ Strategies to promote CRP and reduce moral distress are recommended, to promote work engagement ▸ Further studies required on the role of education in nurses’ work engagement recommend
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Sannino et al17 | Italy | Nurses n=472 (86% response rate)
(15 level III NICUs) | 406 |
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▸ To evaluate the frequency, intensity and level of moral distress experienced by nurses working in NICUs ▸ To assess whether nurses working in NICUs with >/=1000 deliveries/year experience a higher frequency, intensity and level of moral distress than nurses working in NICUs <1000 deliveries
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▸ Low moral distress rate as measured by MDS. Initiating care when felt futile ranked highest cause of moral distress ▸ No association between the number of deliveries in a centre and the moral distress of nurses
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| Sample limited to Northern Italy | Further studies required in neonatal context |
Molloy et al16 | Canada | Nurses
(Tertiary academic referral hospital) | 15 |
| To increase understanding of moral distress experienced by nurses involved in the decision-making regarding resuscitation of neonates at the margins of viability (<25+6 weeks) | Nurses perceive a lack of power and influence in the neonatal resuscitation decision-making process |
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▸ Provide staff with coping mechanisms ▸ Engage more effective communication strategies ▸ Additional research on why nurses feel helpless in decision-making
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Sauerland et al7 (Part II) | USA | Nurses working in NICU/PICU and intermediate care settings n=152 (35% response rate)
(Academic safety net hospital—provides significant service to lower socioeconomic population) | 53 |
| To explore perceptions of moral distress, moral residue and ethical climate among registered nurses |
▸ PICU and NICU nurses experience less moral distress than those in adult ICUs ▸ Greatest distress caused by inadequate staffing, incompetent staff, performing unnecessary tests and treatments and continuing life support when not in child's best interest ▸ Work climate was ranked as moderately ethical
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▸ Work climate ▸ Moral distress
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| Intervention studies that address moral distress at the individual, intraprofessional/interprofessional environment and hospital policies |
Trotochaud et al19 | USA | Multidisciplinary paediatric healthcare providers
| 1113
84 38 79 47 |
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▸ To determine the degree of moral distress experienced by paediatric providers from different professional groups and working in different clinical settings ▸ To describe the relationship of moral distress to paediatric provider intent to leave ▸ To identify situations more likely to be associated with paediatric provider moral distress
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▸ Both physicians and nurses experience moral distress (percentage, describe) ▸ ‘Aggressive’ burdensome end-of-life care not considered appropriate is commonly associated with moral distress
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▸ Moral distress ▸ ‘Aggressive treatment’ ▸ Teamwork
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| Strategies that help providers recognise morally distressing situations when experienced |
Wall et al20 | Canada | Multidisciplinary
| 16 3 1 1 7 3 1 |
| To explore organisational influences on moral distress for healthcare professionals working in PICUs | Individual experience, ethical climate and organisational structures are intertwined in creating moral distress |
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| Further exploration of the impact of organisational structures on moral distress is required |