Moral Distress of ICU Nurses and Palliative Care in the ICU
Krista L. Wolcott
Background: ICU nurses, who care for patients at end of life, have reported high levels of moral distress. Moral distress is experienced when one is unable to deliver the care believed due to a patient and is associated with nurse burnout and patient care avoidance behaviors. Previous studies have linked ethical climate and nurse empowerment with moral distress. No previous studies have directly assessed the relationship between access to palliative care in the ICU and the nurse moral distress. Palliative care has been shown to improve patient care, but is still inconsistently available to ICU patients.
Aim: The primary goal of this web-‐based survey of ICU nurses was to evaluate relationships among moral distress, empowerment, ethical climate, and having access to palliative care in the ICU. Additionally, the study aimed to describe current delivery models of palliative care in the ICU and explore primary palliative care education of ICU nurses and possible relationships between palliative care education and moral distress.
Method: Participants were recruited via email and social media through a national database of ICU nurses. Descriptive, correlational, and multiple regression analyses were done on data from several validated instruments including: Moral Distress Scale-‐Revised (MDS-‐R), Moral Distress Thermometer(MDT), Hospital Ethical Climate Scale(HECS), Psychological Empowerment Index(PEI), and one questionnaire that was developed for this study to assess palliative care access and utilization.
Results: Of the 288 ICU nurses who initiated a survey, 238 completed the surveys and were included in the study. The sample was primarily Caucasian, female and had bachelor’s degrees. They represented a range of ages and years’ of experience in nursing and in the ICU, they worked in a variety of ICU settings and they represented an even distribution of geographical regions in the U.S. Negative correlations were found between MDS-‐R and HECS, and a curvilinear relationship was found between MDS-‐R and PEI. Additionally, those who reported access to a full palliative care team (73%) scored higher on the MDS-‐R than those without access to a full palliative care team. Multiple regression analysis showed ethical climate, ethnicity, number of beds in the unit, access to a palliative care team, and educational degree explained 37.7% of the variance of moral distress. Palliative care teams varied in how present they were in the unit, with social workers reported as the most frequently identified team member, and other disciplines (physician, nurse practitioner, clinical nurse specialist, spiritual care practitioner) were reported present by less than half of the participants. Highest ranked unmet palliative care needs included: psychological support for patients, family support, and goals of care conversations. The most common triggers for a palliative care consult included: prognosis/goals of care/futility conversations, pain/symptom management, imminently dying patient, family support/conflict resolution. The majority of participants reported having had some education on palliative care topics (e.g., management of pain, depression and anxiety, communication about prognosis, goals of care, suffering and code status). For each topic (except communication about code status) those who reported having had palliative care education scored lower on both the MDS-‐R and Moral Distress Intensity (MDI) than those who did not have education. There was no difference in moral distress levels between those who had code status education and those who did not. No difference was found in MDT for any educational topic.
Conclusion: Moral distress is present among ICU nurses related to end of life care, and is related to ethical climate and empowerment. Highly empowered nurses working in a positive ethical climate are likely to experience less moral distress. The existence of palliative care teams does not equate with adequate utilization or well-‐integrated palliative care delivery. Primary palliative care education for ICU nurses may contribute to less moral distress when combined with well-‐integrated care teams and positive ethical climates. The findings from this study highlight the need for the promotion of organizational team-‐building, enhanced palliative care education for ICU clinicians, and development of standardized palliative care delivery methods in the ICU.