Moral distress in the intensive care unit

Read the research articles: 
Causes of moral distress in the intensive care unit: A qualitative study.
Moral distress in intensive care unit professionals is associated with profession, age, and years of experience

CARENET member Dr. Peter Dodek, an Intensivist at St. Paul’s Hospital, Vancouver, a scientist at the Center for Health Evaluation and Outcome Sciences, and a Professor of Medicine at the University of British Columbia, recently co-authored two articles in the Journal of Critical Care around moral distress and the factors and characteristics that are associated with this condition. We asked him about his research and what interventions might help reduce moral stress in the ICU.

First could you help us understand what moral distress is?

PD: Moral distress is typically defined as the anger, frustration, guilt and powerlessness that health care professionals experience when they are unable to practice according to their ethical standards. It could, for example, be caused by a difference of opinion between a physician and a nurse around the level of care, or a lack of resources to most optimally treat a patient.


Q. What did your research reveal?

A. We learned that levels of moral distress are different among the different health professions and that there are links between moral distress, and age and years of experience. We also learned that there are a number of causes of moral distress, including poor communication, inconsistent care plans, limited resources, and inconsistencies around end-of-life decision making.


Q. Did any of the findings surprise you?

A. I had expected that age would be a factor, but in fact we found that this is only true only in non-physician, non-nurse health professionals, and it is an inverse relationship. Moral distress is also directly associated with years of experience in nurses.


Q. Why do you think this is the case for other health professionals, but not for nurses?

A. Other ICU health professionals, such as respiratory therapists or social workers, are able to practice in areas outside of the ICU, whereas ICU nurses are trained and required to work in that environment, which is often very stressful. If a young ‘other health professional’ develops moral distress, they can leave the ICU and work somewhere else.  However, it is possible that those who remain in the ICU are the older non-nurse health professionals who have developed moral resilience, and so their levels of moral distress are not as high.


Q. Poor communications was cited as one of the causes of moral distress. Why do you think that is happening?

A. There are a number of reasons for communications breakdown in the ICU. Sometimes things are not clear in a patient’s chart. In addition, a care plan might be developed by one physician, but not fully explained to the next attending physician, who decides on a different plan. The nurses and other health professionals might not be told the reason for the change in plans, and may be left to explain changes to patients and their family members without fully understanding the reasons why. That can be exceptionally stressful.

There was also considerable moral distress experienced by physicians around end-of-life care conversations, and the feeling that other health professionals – in the hospital and in the community – should have had these important conversations with patients before their arrival in the ICU.


Q.  The articles also noted that concerns about other providers’ care for patients can cause moral distress.

A.  Quality of care is an issue for all health care providers. Nurses experience distress as a consequence of what they perceive as being inadequate care by other nurses and physicians. Similarly, sometimes ICU physicians will keep a patient in the ICU because they do not trust that their colleagues outside the ICU (eg. general wards) can provide the level of care provided. There are also concerns around the skill level of residents, and their ability to both deliver care and provide information.  


Q. Your study found that lack of resources and support from management has an impact on moral distress. Should the cost of employee turnover and burnout be taken into account when determining budgets?

A. Absolutely. It is likely costing a lot to manage employee stress leaves and turnover rates, not to mention the cost of recruitment and training. There are many vacancies in ICU settings across the country. 


Q. What do you think can be done to help reduce moral distress in health professionals?

A. In our current publications, we provided a number of recommendations based on our findings, including greater attention to communication across the health care team and more training to facilitate end-of-life discussions and care plans.

We are also currently working on a tool to help health professionals better understand situations where they experience moral distress. Our interactive website will provide the opportunity to describe the situation, think through the problem, and develop hypotheses for actions that will help to reduce feelings of distress and build moral resilience. The data from this tool will also help us understand which common situations are causing moral distress, and what actions can help resolve issues. This aggregate and anonymous information will be provided to both front-line health professionals and to their health care leaders.


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