Moral distress adversely affects the delivery of high-quality patient care and places health care professionals at risk for burnout, moral injury, and the loss of professional integrity.
To investigate whether pediatric critical care professionals are experiencing moral distress during the COVID-19 pandemic and, if so, for what reasons.
An exploratory survey of pediatric critical care professionals was conducted via the Pediatric Acute Lung Injury and Sepsis Investigators Network from April to May 2020. The survey was derived from a framework integrating contemporary literature on moral distress, moral resilience, and expert consensus. Integration of descriptive statistics for quantitative data and thematic analysis for qualitative data yielded mixed insights.
Overall, 85.8% of survey respondents reported moral distress. Nurses reported higher degrees of moral distress than other professional groups. Inducers of moral distress were related to challenges to professional integrity and lack of organizational support. Five themes were identified: (1) psychological safety, (2) expectations of leadership, (3) connectedness through a moral community, (4) professional identity challenges, and (5) professional versus social responsibility. Most respondents were confident in their ability to reason through ethical dilemmas (76.0%) and think clearly when confronting an ethical challenge even when pressured (78.9%).
During the COVID-19 pandemic, pediatric critical care professionals are experiencing moral distress due to various factors that challenge their professional integrity. Despite these challenges, they also exhibit attributes of moral resilience. Organizations have opportunities to cultivate a psychologically safe and healthy work environment to mitigate anticipatory, present, and lingering moral distress.
Beyond anecdotal accounts, little is known about the moral distress experiences of health care professionals working in intensive care settings during the COVID-19 pandemic.1,2 Moral distress occurs when health care professionals know what the right thing to do is in an ethically challenging situation but encounter internal or external constraints in taking that action and sustaining their integrity.3–5
Empirical research links moral distress with adverse outcomes—including burnout, moral injury, diminished well-being, and patient safety deficits— in normal circumstances.6–9 In a pandemic, moral distress may arise with greater intensity owing to new constraints, uncertainty, and the disruption of normal routines. During the COVID-19 pandemic, are pediatric health care professionals experiencing moral distress? If so, what are the sources of that moral distress, and to what extent are the professionals morally resilient under these circumstances? We conducted a survey of pediatric critical care professionals to answer these important questions.
Moral distress occurs when health care professionals are not able to preserve their integrity.
From April to May 2020, we conducted an exploratory survey of a multiprofessional cohort of pediatric critical care workers to investigate their experiences of moral distress during the pandemic. The scientific committee of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network approved the survey for distribution within a network of pediatric intensive care units. The institutional review board at Geisinger Medical Center determined that this study was exempt from the need for approval.
Data Collection Instrument
Well-established inventories of moral distress— the Moral Distress Scale,10 Moral Distress Scale–Revised,11 and Measure of Moral Distress Scale for Healthcare Professionals12 —do not take into account the unique ethical challenges spawned by the current pandemic. Therefore, we created a survey using a systematic approach with pandemic-specific items guided by Messick’s validity framework.13,14 To establish content validity, 3 experts in bioethics (F.D.D.), moral distress (T.A.T.), and moral resilience (C.H.R.) collaborated as a formative committee to develop a conceptual framework, grounded in a set of empirically based hypotheses about moral distress and moral resilience (see Figure), and used this framework to inform the survey design (Supplemental Tables 1 and 2, available online only at www.ajcconline.org).
Survey questions about inducers of and responses to moral distress were developed through our professional reflection and integration of insights from a literature review.6–10 Integrity-related inducers of moral distress were defined as factors that may challenge or sustain commitments to the overall intellectual and moral excellence of the health care professional.5 The questions pertaining to moral resilience incorporated items from the Rushton Moral Resilience Scale.15 The questions about principles for decision-making were derived from bioethics literature on the allocation of scarce resources in public health emergencies.16–18 A summative committee comprising the formative committee members, the content and methodological expert (S.T.), and 3 additional end users (1 nurse, 1 attending physician, and 1 respiratory therapist) verified the survey’s validity and provided feedback to improve the survey’s content and response processes (ie, terms, clarity, and format).19
Before survey distribution, we pilot tested the survey online via SurveyMonkey (Momentive) with 5 potential respondents to assess practicality, feasibility, and clarity. The final survey had 13 closed-ended (5-point) Likert scale questions and 2 open-ended questions (Supplemental Table 1, available online only). We used snowball survey sampling20 through the PALISI Network, starting with the scientific committee members, who then disseminated the survey to other potential respondents within the network. We included any health care professional working in a pediatric intensive care unit within North America and excluded those who worked outside North America.
Data were analyzed using SAS statistical software, version 9.4 (SAS Institute Inc). We used descriptive statistics to summarize respondents’ demographics. The Kruskal-Wallis test was used for multiple group comparisons, followed by the Dwass-Steel-Critchlow-Fligner procedure for pairwise post hoc analysis using pairwise 2-sample Wilcoxon comparisons.21 Reliability was measured using the Cronbach α.22 Given the exploratory nature of the study, we aimed to attain representation across professions and regions, and thus did not calculate the sample size to test a specific hypothesis a priori. Given the snowball sampling, we did not know the sampling end denominator.
The qualitative data were analyzed using an interpretivist approach to thematic analysis.23 Using the quantitative analysis results and the aforementioned conceptual framework, T.A.T. reviewed the data, created a list of codes, and categorized themes. T.A.T. and F.D.D. iteratively reached consensus on the list of finalized themes and representative quotes. To establish trustworthiness of the results, T.A.T. discussed with F.D.D., C.H.R., and S.T. the nuances of the data and potential influences of individual backgrounds (ie, reflexivity).23 Additionally, member checking, a qualitative research technique used for respondent validation of the data, was completed with 3 pediatric critical care health professionals to verify the identified themes and to gain additional insights.
The characteristics of the 337 respondents who completed the survey are listed in Table 1. Physicians and advanced practice providers (APPs) made up 49.0% of the respondents, with nurses, respiratory therapists, and other professionals constituting 26.4%, 15.7%, and 8.9%, respectively. Overall, 89.0% percent of the respondents considered their role to be essential to their organization’s response to the pandemic. A total of 85.8% of respondents (93.3% of nurses, 81.2% of physicians and APPs, and 81.1% of respiratory therapists) reported that they were experiencing varying degrees of moral distress, with 51.6% acknowledging a moderate amount to a great deal of moral distress. Similarly, 85.5% of respondents (92.1% of nurses, 81.2% of physicians and APPs, and 81.1% of respiratory therapists) reported that after facing a challenging ethical situation, lingering distress weighed them down to various degrees, with 54.0% acknowledging that it weighed them down a moderate amount to a great deal.
“Saving as many lives as possible” was one of the highest-scoring ethical principles that could inform decisions about triage or resource allocation.
Ethical Principles Informing Decision-making
Of the several ethical principles that could inform decisions about triage or resource allocation, the 2 highest-scoring principles were “saving as many lives as possible” and “saving as many life-years as possible” (Supplemental Table 3, available online only).16–18 The “first come, first serve” principle was more highly regarded by nurses and respiratory therapists than by physicians and APPs (P = .03 and P = .005, respectively). In a hypothetical choice of only 1 ethical principle with which to make decisions, 52.2% of the respondents selected the principle of “saving as many lives as possible” and 28.5% selected “saving as many life-years as possible.”
Moral Distress Inducers
Overall, respondents reported being morally distressed to various degrees about the potential for spreading infection to loved ones at home (93.8%), working with limited resources (89.0%), and witnessing their patients dying alone (88.0%). The descriptive statistics of other moral distress inducers are presented in Table 2. According to the post hoc analysis (Supplemental Table 4, available online only), nurses and respiratory therapists were significantly more distressed than physicians and APPs about working with limited resources. Nurses reported significantly higher levels of moral distress than physicians and APPs about having to assume other responsibilities outside of their current professional role (P = .01) and experiencing negative consequences at work for voicing safety concerns (P = .03).
Lack of Organizational Support
The respondents across professions reported the need for more effective organizational support, as outlined in Table 2. Overall, respondents reported that their organizations were quite effective in developing crisis response policies, providing communication updates, and offering staff emotional support services during the pandemic. However, there was collective agreement across all professional roles that organizations were not effective in providing information regarding hazard supplemental compensation for staff during the pandemic. Whereas the physicians and APPs perceived organizational support in other areas to be effective, nurses and respiratory therapists highlighted room for improvement in having forums with leaders to share concerns, an environment that promotes speaking up about concerns without fear of retaliation, opportunities for individual or team-based approaches to address stress, information regarding confidential reporting mechanisms within the organization, and pathways for requesting ethics consultations or advice.
Effective organizational environments promote speaking up about concerns without fear of retaliation.
Moral Resilience Attributes
Survey questions designed to assess the respondents’ moral resilience (Table 3; Supplemental Table 2, available online only)—the capacity of an individual to sustain or restore their integrity in response to moral adversity24 —were selected from a validated scale.15 Overall, 76.0% of the respondents reported being confident (quite confident to extremely confident) in their ability to reason through ethical dilemmas in their professional role, and 78.9% were confident (a moderate amount to a great deal) in their ability to think clearly when confronting an ethical challenge even when pressured. We observed reverse correlation between moral resilience items and the presence of moral distress and lingering moral distress (Supplemental Table 5, available online only).
Integrated Qualitative and Quantitative Analysis
We identified 5 themes from the qualitative data: (1) psychological safety, (2) expectations of leadership, (3) connectedness through a moral community, (4) professional identity challenges, and (5) professional versus social responsibility. The themes, descriptions, and examples of quotes are included in a joint display (Table 4) that brings the quantitative and qualitative data together visually.25 This integration yields clarity, confirmation, or mixed insights from our respondents’ perspectives that might not be as apparent from interpreting quantitative or qualitative data alone.25 As evidenced in mixed insights, most respondents felt distressed by commitments to fulfill their professional responsibilities and being exposed to personal health risks without the same commitments from society at large. For instance, respondents expressed tension between being called “heroes” and witnessing inconsistent behaviors and attitudes of the public. Although concerns regarding psychological safety and expectations of leadership, or lack thereof, were expressed strongly in narrative comments, survey data indicated that these issues were not as prominent as expected. For example, only about 20% of respondents reported that their organizations’ leadership forums and policies regarding crisis response were not effective. Additionally, a large portion of respondents perceived their professional integrity as being challenged by issues related to (but not limited to) scope of practice, loss of control, and perceived inequity among the health care teams. This perception was highlighted by high levels of reported anticipatory moral distress (82.5%) regarding having to make decisions to limit or forgo treatments for patients without the usual level of patient involvement and narrative comments regarding concerns about colleagues’ professionalism in their responses to pandemic stresses.
With the advent of the COVID-19 pandemic and the rapid emergence of complex ethical challenges, we sought to investigate the moral distress experiences of pediatric critical care professionals during the pandemic. In our conceptual framework, through the lens of integrity-related inducers of moral distress and moral resilience, we gained contextual insights about the impact of this pandemic on respondents’ moral lives. Our study yielded 4 key findings. First, although respondents were not confronting firsthand the same magnitude of morbidity and mortality and work demands as adult critical care professionals, they were nonetheless experiencing direct or anticipatory moral distress. Second, nurses had higher degrees of moral distress than other professional groups. Third, the primary cause of moral distress among the respondents was experiencing specific challenges to professional integrity generated by the pandemic. Fourth, despite these challenges, health care professionals had the capacity to be morally resilient.
The prevalence of moral distress among our respondents is not surprising. In normal circumstances, moral distress is an inherent “occupational hazard” in health care.4–8 What is interesting is the way in which the pandemic has surfaced many of the underlying internal and external characteristics of this phenomenon.6–10 Moral distress in pediatric health care professionals could be due to many factors, including the unavoidable uncertainty that this pandemic entails; anticipatory distress in the face of potential spread from adult to pediatric populations; or, as our qualitative data indicate, feelings of guilt engendered by a sense of connection with adult critical care colleagues who have suffered the brunt of the pandemic’s impact. In addition, the lingering moral distress that most of the respondents have experienced during the pandemic could point to the accumulated residue and crescendo effect of unresolved, unrelieved moral distress from the prepandemic period.26
Moral resilience: the capacity of an individual to sustain or restore their integrity in response to moral adversity.
Our findings reinforce that nurses, who provide the most direct bedside patient care, are experiencing more moral distress related to personal and professional integrity compared with physicians and APPs. This finding is consistent with previous studies on moral distress indicating that nurses are more likely to experience moral distress than other health care professionals.8,11,12 In our study, nurses reported being morally distressed about the prospect of losing the ability to advocate for patients’ needs, having to implement decisions to limit or forgo interventions for their patients, and having to communicate changes in policy about limiting or forgoing treatments to patients. Interestingly, nurses reported higher degrees of distress regarding the potential shift of decision-making authority to hospital triage officers or teams and the prospect of disrupted therapeutic relationships with their patients due to the pandemic. These are conditions that might undermine efforts to preserve the integrity essential to their professional identity and to fulfill their commitment to act as their patients’ advocates.27
Furthermore, nurses reported feeling powerless and experiencing deficits in the psychological safety within their organization that enables them to speak up about concerns without fear of retaliation. This finding could reflect the hierarchical differences in power characterizing professional roles in health care, along with legitimate concerns about retaliation and the punitive culture of some organizations. These findings support calls for organizations to build a culture of psychological safety and relational-integrity pathways to sustain a moral community for all health care professionals and foster relatedness in the workplace.28–31 Lack of psychological safety leads health care professionals, particularly nurses, to fear voicing their concerns and to resign themselves to silence, which is known to exacerbate preventable harms, increase professional burnout, and impede organizational learning, adaptability, innovation, and growth.4,7,28,29
Our findings illuminate the pandemic’s exacerbation of challenges to professional integrity due to various social tensions. Although we had a limited number of survey responses from those experiencing the brunt of the pandemic in the Northeast region, the Children’s Hospital Association, representing more than 220 hospitals nationally, reported that children’s hospitals were strategically preparing their organizations and staff to accommodate adult hospitals’ surge of patients.30,31 Caring for many complex critically ill adults in a children’s hospital was no longer a remote possibility but a current reality for many. Our quantitative and qualitative analyses highlight the significance of anticipatory and present moral distress that our respondents, particularly nurses, have felt in taking on professional roles and responsibilities beyond their scope of expertise. Such a prospect causes anguish because it undermines their professional identity and their sense of moral efficacy in fulfilling the core obligations inherent in that role.4,5,24 Another intriguing finding is the greater importance that nurses and respiratory therapists assign to the ethical principle of “first come, first serve” in anticipatory triage decision-making. This finding might be explored in light of the fundamental shift in decision-making paradigms that the pandemic demands, in which broader social needs are prioritized over individual needs and autonomy-based decision-making.16–18 If health care professionals are not in agreement with the guiding principles of care delivery at the professional level during a pandemic, they are forced to implement decisions at odds with their own values. This experience can be perceived as a violation of their professional integrity as they attempt to fulfill their professional duties or meet the highest standards of their profession.5
Tending to the moral distress experiences of health care professionals … may create a more robust health care workforce.
Our analysis affirms that health care professionals have attributes of moral resilience—the ability to navigate moral conflict and apply ethical solutions to ethical problems,24 even in the midst of a pandemic. Specifically, although respondents reported distress about the prospect of implementing decisions against their values, they also reported that their fears have not led them to compromise their values and that they have confidence in their reasoning abilities. These findings are important indicators of their moral sensitivity and awareness of threats to integrity, throwing into relief 2 important attributes of moral resilience: moral efficacy and the capacity for self-regulation.24 Our findings also highlight the significance of moral resilience, or lack thereof, as lower degrees of moral resilience were associated with the presence of moral distress and with lingering distress in health care professionals. These results illuminate opportunities for organizations to systematically recognize and redress contributing factors to anticipatory, present, and lingering experiences of moral distress and to bolster training to support the moral efficacy of health care professionals—their capacity to face ethical challenges without complacency, unregulated moral outrage, or compromised integrity.32,33 Moreover, our findings highlight the relationship between moral climate and moral distress and the important role of ethical cultures in fostering healthy workplaces.29,34,35 Taking into account the immediate and long-term detrimental effects of moral distress on health care professionals and the unknown impact this pandemic will have on the current and future workforce, we suggest that organizations take heed of these findings and the recommendations of the National Academy of Medicine34 to not only create an ethical work environment that strengthens professional integrity but also cultivate a psychologically safe environment to prevent a “parallel pandemic” of burnout among health care professionals.29,32–35 Establishing safe forums to share concerns with colleagues and leaders may also foster relational integrity and moral efficacy for health care professionals—key attributes to sustaining moral resilience in the midst of distress.24 The ultimate rationale for such initiatives is this: tending to the moral distress experiences of health care professionals, both during and beyond the pandemic, may help create a more robust health care workforce that can better meet patients’ needs.
Our study has several limitations. This was an exploratory survey, and thus our findings cannot be assumed to be representative or generalizable. The sample size was small, and the survey was conducted over a short period, possibly limiting our potential responses and recruitment opportunities. Given the unforeseen nature of the pandemic, we cannot with absolute certainty tease apart the effects of the COVID-19 pandemic from those of typical work situations. The qualitative data, however, helped to illuminate the effect of the pandemic on the respondents. Additionally, the snowball recruitment process may have limited the survey response rate and may have introduced bias, with only those interested responding and then possibly recruiting others with similar interests to participate. We used this method because of the time constraints imposed by a rapidly progressing pandemic and to maintain anonymity within a smaller, well-connected medical community of pediatric critical care professionals. Also, at the time of this survey, the pandemic epicenter was in the Northeast region of the country. Thus, the limited number of respondents from that region could have been due to acute clinical burdens, increased organizational planning, and survey fatigue during this period. We acknowledge that the smaller response from those in the Northeast region limits the knowledge, insights, and conclusions that can be garnered about present moral distress experiences during the pandemic.
The results of our study suggest that during the COVID-19 pandemic, pediatric critical care professionals are experiencing moral distress due to various factors that challenge their professional integrity. An especially high proportion of nurses reported moral distress, felt that their professional integrity was threatened, and perceived a lack of organizational support. Despite these challenges, they also demonstrated attributes of moral resilience. Further studies are needed to investigate the impact of pandemic-specific moral distress experiences on various health care professionals. Lessons learned may yield increased attention to the need for organizational support, structure, and action to develop strategies not only to prevent and mitigate moral distress but also to sustain organizational, team, and individual moral resilience during the COVID-19 pandemic and beyond.
Drs Thammasitboon and Rushton served as co–senior authors and contributed equally to this work. We thank the PALISI Network for distributing the survey to its member list. We are also grateful to the survey respondents for their participation.
For more about moral distress, visit the AACN Advanced Critical Care website, www.aacnacconline.org, and read the article by Rushton et al, “Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?” (Spring 2021).
To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, firstname.lastname@example.org.