PICU Clinicians Report Moral Distress, Ethical Concerns

During the initial surge of COVID-19 in the United States, pediatric critical care professionals were already experiencing high rates of moral distress as they faced the rapid emergence of complex ethical challenges and the potential impact of COVID-19 on their young patients and their communities, according to a study published in American Journal of Critical Care.

“COVID-19 and Moral Distress: A Pediatric Critical Care Survey” reports the results of an exploratory survey of pediatric critical care professionals conducted in April and May 2020. The survey was sent to the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) research network of pediatric intensive care units (PICUs) in North America, and 337 participants responded. Nearly half were physicians and advanced practice providers, with nurses, respiratory therapists and other professionals constituting 26.4%, 15.7% and 8.9% respectively.

A total of 85.8% of respondents reported that they were experiencing varying degrees of moral distress. A similar number reported that after facing a challenging ethical situation, lingering distress continued to weigh them down.

Co-author Tessy A. Thomas, DO, MBE, is an assistant professor of pediatrics and bioethics at the Center for Translational Bioethics and Health Policy and Janet Weis Children’s Hospital, Geisinger Medical Center, Danville, Pennsylvania. Three experts in bioethics, moral distress and moral resilience collaborated as a formative committee to develop a conceptual framework, inform the survey design and provide insights on the nuances of the data.

“The pandemic brought to the surface many of the underlying chronic internal and external characteristics of moral distress. In addition, the lingering distress reported by most of the survey respondents could point to the previously reported accumulated residue and crescendo effect of unresolved, unrelieved issues from before the pandemic,” Dr. Thomas said. “Our findings highlight the opportunity for organizations to cultivate healthy work environments and moral climates to mitigate anticipatory, present, and lingering moral distress for all health care professionals. Tending to the moral distress experiences of health care professionals may create a more robust health care workforce.”

Among the findings:

• Although respondents were not confronting firsthand the same magnitude of morbidity and mortality as colleagues caring for adult patients, they were nonetheless experiencing direct or anticipatory moral distress.
• Nurses had higher degrees of moral distress than other professional groups.
• Challenges to their professional integrity during the pandemic was the main cause of moral distress for respondents.
• Despite these challenges, healthcare professionals had the capacity to be morally resilient.

The qualitative data analysis revealed five key themes associated with moral distress, including psychological safety, expectations of leadership, connectedness through a moral community, professional identity challenges and professional versus social responsibility. The results illuminate how clinicians often struggled to maintain their professional identities, roles, expectations and collegial relationships during the initial surge of the pandemic.

The findings also support calls for organizations to foster healthy work environments and build a culture of psychological safety in which healthcare professionals can voice concerns without fear of retaliation or censure.

To access the article and full-text PDF, visit the AJCC website at www.ajcconline.org. The analysis instrument, conceptual framework and principles influencing anticipatory decisions about triage/resource allocation by healthcare professionals are available as online-only supplemental resources to the journal article.

About the American Journal of Critical Care: The American Journal of Critical Care (AJCC), a bimonthly scientific journal published by the American Association of Critical-Care Nurses, provides leading-edge clinical research that focuses on evidence-based-practice applications. Established in 1992, the award-winning journal includes clinical and research studies, case reports, editorials and commentaries. AJCC enjoys a circulation of more than 130,000 acute and critical care nurses and can be accessed at www.ajcconline.org.

About the American Association of Critical-Care Nurses: For more than 50 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. AACN is the world’s largest specialty nursing organization, with more than 130,000 members and over 200 chapters in the United States.

American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656; 949-362-2000; www.aacn.org; facebook.com/aacnface; twitter.com/aacnme