Causes of moral distress in the intensive care unit: A qualitative study

doi:10.1016/j.jcrc.2016.04.033

Journal of Critical Care

Volume 35, October 2016, Pages 57-62

https://doi.org/10.1016/j.jcrc.2016.04.033 Get rights and content

Abstract

Purpose

The purpose of the study is to examine the causes of moral distress in diverse members of the intensive care unit (ICU) team in both community and tertiary ICUs.

Materials and methods

We used focus groups and coding of transcripts into themes and subthemes in 2 tertiary care ICUs and 1 community ICU.

Results

Based on input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported causes of moral distress were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), poor communication, inconsistent care plans, and issues around end of life decision making.

Conclusions

Causes of moral distress vary among ICU professional groups, but all are amenable to improvement.

Introduction

Moral distress is the anger, frustration, guilt, and powerlessness that health care professionals experience when they are unable to practice according to their ethical standards [1], [2], [3], [4]. Empirical studies identify significant prevalence and high levels of moral distress in nursing practice [3], [5] and have linked moral distress to burnout and attrition [6], [7], [8]. Recent research has explored moral distress in other health care disciplines, with similar findings [1], [9], [10], [11], [12], [13]. Quantitative and qualitative studies show that moral distress has a profound effect on nurses and other health care professionals as well as on the quality of interdisciplinary team workplaces and the safety of patients [14], [15].

Although moral distress can be evaluated by both quantitative [5], [11], [15], [16], [17] and qualitative [10], [12], [13], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] means, there have been few qualitative studies of moral distress in intensive care unit (ICU) professionals [20], [26], [33], [34], [35], and none that have addressed moral distress in all ICU professionals in both community and tertiary ICUs. Therefore, the purpose of this study was to examine the causes and consequences of moral distress in diverse members of the ICU team in both community and tertiary ICUs. This article describes the causes of moral distress.

Section snippets

Materials and methods

A study on moral distress in ICUs was conducted in all 13 ICUs in the Vancouver area in British Columbia, Canada, in 2011 and 2012. First, a quantitative survey was completed by nurses, physicians, and other health professionals in all of the participating units [36]. Then, all ICU clinical staff in 3 of the participating hospitals (see Supplementary Digital Content for selection criteria) were invited to participate in focus groups to address causes and consequences of moral distress. Focus

Results

A total of 10 focus groups and 4 interviews were conducted. At each of the 3 hospitals, 1 focus group was conducted with each provider type, and a fourth group was conducted with clinical nurse leaders at one hospital. The interviews included 3 nurses and 1 other health professional. A total of 56 providers participated in the focus groups (Table 1). In the following description, quotations from participants are included verbatim except where clarifications are required or to maintain

Discussion

Focus groups with health care providers in 3 ICUs revealed many causes of moral distress. The causes mentioned in the most focus groups were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), and poor communication. The causes that were mentioned most frequently were concerns about the care provided by other health care workers, inconsistent care plans, and issues around end-of-life decision making. Our finding

Conclusions

Causes of moral distress can broadly be categorized into 8 categories: quality of care, amount of care provided, inconsistent care plans, end-of-life decision making, poor communication, interactions/conflict between ICU staff and family, recommendations for patient care ignored by other staff, and lack of support or resources. Interventions to address moral distress should consider these specific causes and the target groups and settings where they apply.

Acknowledgments

The authors thank all of the health care professionals who participated voluntarily in this project and Sarah Shepherd for organizing the focus groups.

Financial support: Canadian Institutes for Health Research (funding reference no. 106278), Providence Health Care Research Institute, Center for Health Evaluation and Outcome Sciences, St Paul's Hospital Foundation, BC Patient Safety and Quality Council, BC Nurses' Union, and BC Chair in Patient Safety.

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^☆: None of the authors has any financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

View full text

CommunicationCauses of moral distress in the intensive care unit: A qualitative study☆

Abstract

Purpose

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgments

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

Crit Care Med

Nursing practice: the ethical issues

Moral agency: relational connections and support

Moral residue

Registered nurses' perceptions of moral distress and ethical climate

Nurs Ethics

Moral distress in health care professionals. What is it and what can we do about it?

The Pharos

Critical care nurses' perceptions of futile care and its effect on burnout

Am J Crit Care

Policy, procedure and routine: matters of moral influence

Nurs Sci Q

Moral distress and the contemporary plight of health professionals

HEC Forum

The balancing act: psychiatrists' experience of moral distress

Med Health Care Philos

“We are white coats whirling round”—moral distress in Swedish pharmacies

Pharm World Sci

Moral distress experienced by health care professionals who provide home-based palliative care

Soc Sci Med

Moral distress among health system managers: exploratory research in two British Columbia health authorities

Health Care Anal

Moral distress in healthcare practice: the situation of nurses

HEC Forum

Development and testing of an instrument to measure moral distress in healthcare professionals

AJOB Prim Res

Medical students' experiences of moral distress: development of a web-based survey

Acad Med

Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital

J Nurs Manag

Living with conflicts-ethical dilemmas and moral distress in the health care system

Soc Sci Med

Nurses' perceptions of and responses to morally distressing situations

Nurs Ethics

Iranian intensive care unit nurses' moral distress: a content analysis

Nurs Ethics

Communication
Causes of moral distress in the intensive care unit: A qualitative study☆