Although use of mechanical circulatory support is increasing, it is unclear how providing such care affects clinicians’ moral distress.
To measure moral distress among intensive care unit clinicians who commonly care for patients receiving mechanical circulatory support.
In this prospective study, the Moral Distress Scale-Revised was administered to physicians, nurses, and advanced practice providers from 2 intensive care units in an academic medical center. Linear regression was used to assess whether moral distress was associated with clinician type, burnout, or desire to leave one’s job. Clinicians’ likelihood of reporting frequent moral distress when caring for patients receiving mechanical circulatory support vs other critically ill patients also was assessed.
The sample comprised 102 clinicians who had a mean (SD) score of 100.5 (51.6) on the Moral Distress Scale- Revised. After adjustment for clinician characteristics, moral distress was significantly higher in registered nurses than physicians/advanced practice providers (115.9 vs 71.0, P < .001), clinicians reporting burnout vs those who did not (114.7 vs 83.1, P = .003), and those considering leaving vs those who were not (121.1 vs 89.2, P = .001). Clinicians were more likely to report experiencing frequent moral distress when caring for patients receiving mechanical circulatory support (26.5%) than when caring for patients needing routine care (10.8%; P = .004), but less likely than when caring for patients with either chronic critical illness (57.8%) or multisystem organ failure (56.9%; both P < .001).
Moral distress was high among clinicians who commonly care for patients receiving mechanical circulatory support, suggesting that use of this therapy may affect well-being among intensive care unit clinicians.
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Identify 3 clinician characteristics that are associated with higher levels of moral distress.
Identify 2 clinician outcomes that are associated with higher levels of moral distress.
Identify 3 potential interventions that may help to alleviate moral distress in intensive care unit clinicians.
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Moral distress occurs when clinicians provide care antithetical to their personal and professional beliefs,1–4 and it may arise in situations where clinicians must provide aggressive care with unclear benefit.2,5 Moral distress is harmful for care providers; research shows that it contributes to burnout, job dissatisfaction, and attrition.1,2,6 It may also be harmful for patients, as moral distress has been associated with clinicians having worse perceptions of the quality and safety of care and with clinicians withdrawing from patients.5,7–9
In an intensive care unit (ICU), where patients often receive aggressive care in the form of life-sustaining therapy, morally distressing situations may be more likely to occur than in other hospital units.10 Although moral distress is high among clinicians in ICUs,3,4,11 few studies have investigated the prevalence of moral distress among clinicians caring for patients receiving mechanical circulatory support (MCS).
The scope of MCS, in the form of both right and left ventricular assist devices and extracorporeal membrane oxygenation, has expanded throughout the past decade. Initially developed as a bridge to transplantation, MCS currently is used for both short- and long-term support, ranging from hours to years, for a variety of indications and goals of care.12,13 Overall 2-year survival is 70% among patients receiving MCS12 ; however, morbidity in the form of debilitating stroke, significant bleeding, and infection continue to be significant barriers and challenges to patients, their families, and clinicians. As such, this relatively new form of life-sustaining therapy may cause high prognostic uncertainty and unacceptable quality of life.
As with any life-prolonging technological advance, use of MCS may lead to more need for morally distressing clinical care, but empirical evidence is lacking. Therefore, our primary aim in this study was to measure levels of moral distress among clinicians who commonly care for patients receiving MCS. Our secondary aims included examining the association between moral distress and clinician outcomes, exploring how the use of MCS may lead to morally distressing situations in comparison to other types of critically ill patients, and identifying potential interventions for alleviating moral distress among clinicians.
As with any life-prolonging technological advance, use of MCS may lead to more need for morally distressing clinical care, but empirical evidence is lacking.
This study was approved by the Columbia University Irving Medical Center Institutional Review Board (IRB-AAAR9952). We performed a prospective survey of personnel in a medical ICU and a cardiothoracic ICU at an academic medical center in New York City that serves as a main tertiary referral center for the surrounding tristate area. Patients requiring MCS are grouped within these units, and clinicians frequently care for patients undergoing any of the multiple forms of MCS, including venoarterial and venovenous extracorporeal membrane oxygenation and use of an implanted right or left ventricular assist device.
A combination of critical care anesthesiologists, surgical and medical intensivists, nurse practitioners, physician assistants, nurses, critical care fellows, and resident physicians primarily staff these ICUs. We distributed surveys to all attending physicians, advanced practice providers (APPs), and registered nurses in the 2 ICUs; we did not include trainees in order to limit heterogeneity of clinical experience. To facilitate recruitment, we distributed surveys both online via the Qualtrics platform and in person as hard copies. For electronic surveys, we sent clinicians an initial email and up to 3 follow-up requests with survey links in each email to encourage completion. Blank hard-copy surveys were left in the ICU, and a labeled, locked metal box was placed in the ICU to allow clinicians to complete and return the survey at their convenience. Survey completion was voluntary, and participants were reminded of this both verbally and in writing via information sheets attached to the surveys. We obtained informed consent from participants before they completed the survey electronically or on paper.
The survey first collected information about participant demographics including age, sex, race, relationship status, years in practice, clinical role (physician, APP, or nurse), and primary ICU (medical or cardiothoracic). The survey also collected details about participants’ experiences of moral distress and potential outcomes related to moral distress. We measured moral distress by using a validated survey instrument, the Moral Distress Scale-Revised (MDS-R). Briefly, each of the 21 items on the MDS-R measures frequency and intensity on a Likert scale from 0 (never) to 4 (very frequently); scores were multiplied in order to obtain a composite number for each item. The composite scores for all 21 questions were added together, for a maximum score of 336. Prior studies have reported levels of moral distress ranging from 70 into the 80s for nurses and from 50 into the 60s for physicians working in an ICU,1,6,11 but no minimum clinically important difference has been determined. Because moral distress has been associated with burnout3,11,14 and increased rates of departure from work,1,15,16 we included on the survey 2 questions from the Maslach Burnout Inventory, both with high concurrent validity,17,18 and we queried participants about their desire to leave their jobs.
We measured moral distress using a validated survey instrument, the Moral Distress Scale-Revised (MDS-R).
In addition, we asked clinicians to rate, using a 5-point Likert scale where 1 represented “never” and 5 represented “very often,” how often they experienced moral distress when caring for various populations of critically ill patients; the item appeared as, “On a scale of 1 to 5, how often do you feel morally distressed when caring for the following patient populations?” Providers within each ICU had chosen patient archetypes to represent patient populations they commonly encountered, with varying severity of illness and varied use of other life-sustaining therapies. Because the MDS-R assesses clinicians’ moral distress generally (ie, not in relation to the specific care of a patient), the goal of this investigator-generated question was to assess how often clinicians viewed caring for a patient receiving MCS as a morally distressing situation, as opposed to caring for a “routine” patient in the ICU (which would not be expected to engender much moral distress) or for other patients with a severe illness and requiring a different life-sustaining therapy in the ICU (which may be as likely or more likely to engender moral distress).
The cardiothoracic ICU survey included (1) a routine postoperative patient with an ICU length of stay less than 10 days, (2) a patient with a temporary MCS device, (3) a patient with a permanent MCS device, (4) a patient with a chronic critical illness, and (5) a patient with prolonged multisystem organ failure. The medical ICU survey included (1) a stable patient with interstitial lung disease receiving oxygen via a high-flow nasal cannula while awaiting lung transplantation, (2) a patient receiving venovenous extracorporeal membrane oxygenation for respiratory failure, (3) a patient with advanced cancer and respiratory failure, (4) a patient with a chronic critical illness, and (5) a patient with prolonged multi-system organ failure. Last, the survey asked clinicians to choose as many interventions as they thought would be most useful for addressing moral distress (eg, increasing the use of palliative care consultation, having regular debriefing sessions).
We included surveys in the analyses when no more than 3 question responses were missing. For the surveys included, any missing responses were scored as zero. We summarized baseline demographics for the study participants and identified characteristics associated with higher levels of moral distress using bivariate statistics. Using linear regression and adjusting for demographic characteristics that demonstrated significance in bivariate testing, we determined whether moral distress was associated with clinician type, burnout (defined as a report of either depersonalization or emotional exhaustion on the Maslach Burnout Inventory), and a desire to leave one’s job. We examined, using the 2-sample test of proportions, whether clinicians were more likely to report frequent moral distress (defined as a rating of 4 or 5 on the Likert scale) when caring for patients receiving MCS than when caring for other common patients in ICUs. We also determined which interventions clinicians most frequently endorsed as being helpful for alleviating moral distress. We performed statistical analysis using Stata software version 16.1 (StataCorp).
The overall response rate was 39.5%, with 135 clinicians participating in the survey. Of those responses, 33 (24%) were excluded because of missing data. The final study sample comprised 102 ICU clinicians (67 nurses, 28 physicians, 7 APPs) who provided complete data for analysis; 34 of the 102 surveys (33.3%) were completed as hard copies. Table 1 details demographic characteristics of the study participants.
The mean (SD) MDS-R score for the overall sample was 100.5 (51.6). Moral distress was higher among clinicians who were female, were of “other” race (ie, Asian/American Indian or Alaska Native/Native Hawaiian or Pacific Islander), were single or divorced, and had 10 or more years in practice (Table 2). Of all clinicians, 56 (54.9%) provided responses consistent with burnout and 36 (35.3%) reported considering leaving, or wanting to leave, their position.
Results of multivariable linear regression, after adjustment for sex, race, relationship status, and years in practice, demonstrated that moral distress was higher among nurses (mean [SD] MDS-R score, 115.9 [53.4]) than among physicians and APPs (71.0 [31.7], β = 41.8 [95% CI, 21.6-62.1], P < .001). Moral distress was also significantly higher for clinicians who reported burnout (mean [SD] MDS-R score, 114.7 [51.0]) than those who did not (83.1 [47.3], β = 30.0 [95% CI, 10.4-49.5], P = .003) and for those considering leaving their position (121.1 [47.7]) than those who are not (89.2 [50.5], β = 31.6 [95% CI, 12.6-50.5], P = .001).
Clinicians were significantly more likely to report experiencing frequent moral distress when caring for patients receiving either temporary or permanent MCS (26.5%) than when caring for routine patients (ie, a routine postoperative patient for cardiothoracic ICU personnel, a stable patient with interstitial lung disease for medical ICU personnel) (10.8%, P = .004). Clinicians were significantly less likely to report experiencing frequent moral distress when caring for patients receiving MCS (26.5%) than when caring for either patients with chronic critical illness (57.8%, P < .001) or patients with multisystem organ failure (56.9%, P < .001). For medical ICU respondents, clinicians were not significantly more likely to report frequent moral distress when caring for patients receiving MCS (26.5%) than when caring for patients with advanced cancer and respiratory failure (17.7%; P = .13).
Overall, clinicians selected palliative care consultation, ethics consultation, and debriefing sessions as the interventions whose increased use would most likely help alleviate moral distress, although some differences were apparent between clinician types (see Figure). Increasing use of palliative care consultation was selected most frequently, by 75% of all respondents (88% of nurses, 51% of physicians/APPs). Approximately 64% of respondents (82% of nurses, 29% of physicians/APPs) chose increasing use of ethics consultation, and 63% of respondents (64% of nurses, 57% of physicians/APPs) chose debriefing sessions.
In our study, we identified high levels of moral distress among clinicians who commonly care for patients receiving MCS; these clinicians had higher MDS-R scores than those reported in prior studies.2,4,6 In concordance with other studies, we found that nurses experienced a higher level of moral distress than either physicians or APPs, which may be because of their proximity to patients when delivering care in morally distressing situations, and we found that clinicians who were either single or divorced had higher levels of moral distress.1–4,11 Moral distress was also higher for clinicians who had been practicing more than 10 years, which may be due to a “crescendo effect” whereby repeated instances of unaddressed moral distress result in a greater level of moral distress over time.11,19 Not surprisingly, we also found that moral distress was significantly higher among clinicians who reported burnout and considered leaving their position.3,14
Clinicians selected palliative care consultation, ethics consultation, and debriefing sessions as the interventions most likely to help alleviate moral distress.
Intriguingly, despite the overall high levels of moral distress, clinicians were less likely to report experiencing frequent moral distress when taking care of patients receiving MCS than when caring for patients with a chronic critical illness or sustained multisystem organ failure. This finding raises the question of whether the high levels of moral distress reported may be due to the high severity of illness—often associated with longer stays and higher in-hospital mortality—among the overall ICU patient population. Moreover, these data suggest that moral distress arising from the use of MCS may not differ substantially from, or may even be less than, moral distress associated with the use of other life-sustaining therapies such as prolonged mechanical ventilation. This finding should, however, be viewed as preliminary, as the method we used to compare moral distress arising from providing care to different patient populations has not been used previously. Further studies are needed to determine whether use of MCS independently increases the risk of frequent moral distress among clinicians, and whether its use might increase moral distress by prolonging patient survival and thereby enlarging the population of patients with chronic critical illness or prolonged multisystem organ failure.
Providers chose palliative care consultation , ethics consultation, and debriefing sessions as the interventions whose increased use would be most likely to help reduce moral distress. Published recommendations for promoting “moral resilience” in individual practitioners support the potential for these interventions to affect moral distress, citing the need for “consultants who can facilitate ethics-related conversations” and an “environment that fosters reflection and communication.”20(pS4) We did not, however, evaluate in this study whether these interventions may provide concrete benefit. Other potential interventions may alleviate moral distress, including more extensive ethics education, retreats during which clinicians reflect on distressing situations, increased interdisciplinary communication, and more institutional programs to improve the ethical climate, but few have been rigorously tested.21,22
Our study is limited in several ways. We included a small sample from a single academic medical center, limiting the generalizability of our findings. Although the moral distress scores among our study population are higher than scores that have been reported previously, no standard exists for a “high” or “low” level of moral distress, making it difficult to perform direct comparisons. Furthermore, because we were primarily interested in documenting moral distress arising from caring for patients receiving MCS, we did not have a “control” population of ICU clinicians who do not care for such patients. We aimed to address this issue in part by asking clinicians to rate their moral distress when caring for various types of critically ill patients, but this method has not been validated.
We found that moral distress was high among ICU clinicians who commonly care for patients receiving MCS; nurses reported significantly higher levels of moral distress than did physicians and APPs. Similar to findings from prior studies, clinicians with higher levels of moral distress were more likely than those with lower levels to report burnout and a desire to leave their job. These data suggest that use of MCS may be an additional factor to consider when assessing the health of the work environment and how it might affect ICU clinicians’ moral distress and well-being. Further research is needed in order to develop these findings. In particular, qualitative or mixed-methods studies may help determine whether frequently caring for patients receiving MCS is an independent risk factor for moral distress and identify effective interventions to address clinicians’ moral distress.
Evidence-Based Review on pp 363-364
Dr Hua is supported by a Paul B. Beeson Career Development Award (award no. K08AG051184) from the National Institute on Aging, National Institutes of Health, and the American Federation for Aging Research. The funders were not involved in the design or conduct of the study, interpretation of data, preparation of the manuscript, or the decision to submit the manuscript for publication.
For more about moral distress, visit the AACN Advanced Critical Care Nurse website, www.aacnacconline.org, and read the article by Epstein et al, “Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community” (Summer 2020).
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