Original articleThe relationship between moral distress and perception of futile care in the critical care unit☆
Introduction
Great emphasis has been placed traditionally on stresses from workload, staffing and families’ demands to explain the “burnout” phenomenon in critical care nurses with little attention to the role of moral or ethical conflicts in the work environment (Acker, 1993, Chen and McMurray, 2001, Chiriboga and Bailey, 1986, Khowaja et al., 2005, Meltzer and Huckabay, 2004, Stechmiller and Yarandi, 1993). Moral distress has been defined as painful feelings or state of psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it, because of such obstacles as lack of time, supervisory reluctance, an inhibiting medical power structure, institution policy, or legal considerations (Corley, 1995, Erlen and Sereika, 1997, Livingston and Livingston, 1984, Sorlie et al., 2005). The role of moral distress on job satisfaction and turnover among critical care nurses has not been fully elucidated.
Nurses are frequently exposed to death and dying in the critical care environment. The goal of nursing is to provide care for patients in all situations even when it appears that a patient may not progress towards wellness (Beckstrand and Kirchhoff, 2005). Futile care is described as aggressive “treatment” or interventions such as the use of life support therapy in terminally ill patients who are highly unlikely to survive or have a successful outcome (Council on Ethical and Judician Affairs—American Medical Association, 1999). An intervention can be perceived as futile when its goals are not achievable or its degree of success is empirically implausible (Meltzer and Huckabay, 2004). As patients approach the end-of-life, the perception gap of futile care widens between physicians and nurses because of differences in their professional roles (Oberle and Hughes, 2001). The perception gap among healthcare providers arises partially due to judgment disparities in defining realistic goals for treatments and interventions for patient care. Critical care nurses’ perception of futile care has been associated with experience of moral distress and emotional exhaustion with subsequent burnout (Meltzer and Huckabay, 2004). The frequencies of situations of futile care are also increasing because of technical advances in medicine and the growing number of the elderly who are exposed to aggressive care before death (Rady and Johnson, 2004, Angus et al., 2004, Lloyd et al., 2004). However, it remains unclear if years of exposure attenuated the experience of moral distress related to futile care among critical care nurses. The self-reporting of similar intense emotional responses to situations or events has been reported to abate and diminish over time as a coping mechanism to repetitive exposure and to re-establish psychological equilibrium, i.e. hedonic adaptation (Easterlin, 2003). Hedonic adaptation develops in response to past situations to help to deal with emotional impact of similar future encounters. The re-calibration of individual perception has been described as a mechanism for hedonic adaptation (Riis et al., 2005, Wu, 2001). Similar adaptation or re-calibration of perception among health care providers who are involved directly or indirectly with patient care has been proposed to develop over time (Easterlin, 2003).
Corley (1995) developed a Moral Distress Scale, an instrument to measure the intensity and encounter frequency of moral distress for critical care nurses in the hospital setting. The instrument utilizes clinical situations associated with moral conflicts that nurses confront in hospital practice everyday. The categories of clinical situations in the instrument included individual responsibilities of health care providers (physicians, nursing and institutional), care-not-in-the best patient interest (futile care), deception and eusthenasias. The reliability and validity of the Moral Distress Scale has been tested in previous studies (Corley et al., 2001, Corley et al., 2005). Using the Moral Distress Scale instrument, this prospective study tested the hypothesis that the years of practice in the critical care environment attenuated nurses’ moral distress to different categories of clinical situations.
Section snippets
Methods and subjects
The Institutional Review Board approved the study and consent was obtained prior to study participation. The study was a prospective cross-sectional survey of all critical care nurses who worked at a single 30-bed multidisciplinary critical care unit at a tertiary care teaching hospital. The critical care unit consisted of intermediate, coronary and intensive care. Full time critical care staff physicians primarily managed the intensive care patients. Physicians from internal medicine, surgery
Results
Of the 100 critical care nurses who received the survey, 44 nurses completed the survey for analysis (response rate 44%). The median age of respondents was 33 (range 23–60) years with predominance of females 35 (80%). The median years in critical care nursing was 4 (range 0.5–30) and nursing practice was seven (range 1–35). The educational qualification of nurses who completed the survey was: diploma or bachelor degrees in 40 (91%) and masters degree in 4 (9%).
Table 1 depicts the prevalence of
Discussion
The study revealed that the intensity of moral distress was high across the six categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia. The intensity of moral distress was independent of nurses’ demographics. The high intensity of moral distress reported across all categories substantiated the survey as a powerful tool to measure and elicit moral distress in the study subjects. The encounter frequency was the highest for situations related
Conclusions
Moral distress associated with situations of futile care increased with time in the critical care environment. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.
Conflict of interest
There are no affiliations or financial involvement with any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript.
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Presented at the Society of Critical Care Medicine 35th Educational Congress, January 7–11, 2006.