Impact of profession and wards on moral distress in a community hospital

Abstract

Background:

Recently, a singular survey titled “Measure of Moral Distress—Healthcare Professionals,” which addresses shortcomings of previous instruments, has been validated.

Aim:

To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital.

Participant and research context:

We distributed a self-administered, validated survey titled “Measure of Moral Distress—Healthcare Professionals” to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital.

Findings:

A total of 101 surveys were included in the study. The mean Measure of Moral Distress—Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress—Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress—Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress—Healthcare Professionals score mildly greater than the emergency room.

Ethical considerations:

No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center’s Institutional Review Board.

Discussion:

This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress.

Conclusion:

In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress—Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Keywords

Clinical ethics ethics of care/care ethics moral distress nurses professional ethics theory/philosophical perspectives

Introduction

Frontline healthcare workers operate in a high-stakes environment. Such a demanding position places a heavy burden of responsibility and exposes their core values to confrontation. In the current complex healthcare environment, the administered treatment is never dictated by a single individual; instead, the ultimate treatment administered is determined by a conglomerate of practitioners, administrators, and patient/family decisions.¹ Although such a system’s stated goal is equitable and ethical healthcare delivery, this is not always the outcome. Therefore, it becomes commonplace for frontline healthcare workers to act contrary to personal ethical convictions due to the above external constraints.² The derived personal anguish and frustration are classically termed as moral distress.

Multiple studies show that nurses experience significantly more moral distress than physicians, attributed to poor communication, insufficient input to clinical decisions, perceived quality-of-care delivery, and unsafe staffing practices.^3–5 Moral distress also has implications for workforce sustainability, with previous studies revealing that approximately 20% of respondents were considering leaving their positions due to moral distress.^6,7 Several studies have also shown that an elevated level of moral distress is associated with burnout.^8–10

Engagement in vibrant discussions about ethical dilemmas within a healthcare institution is a positive sign of genuine concern for applying fairness and justice to all patients we encounter. However, despite far-reaching implications, the impact of moral distress on frontline care providers is rarely measured in community hospitals. Therefore, it is crucial to measure the prevalence of moral distress and open new discussions on how we can further address our hardworking healthcare team’s well-being. Previously, moral distress, based on Jameton’s definition,² was measured by a validated questionnaire, Moral Distress Scale–Revised (MDS-R), which had multiple versions based on role.¹¹ However, it was later determined that the MDS-R did not capture several aspects of moral distress.^12,13 Recently, a singular survey, “Measure of Moral Distress—Healthcare Professionals (MMD-HP),”¹² which addresses previous shortcomings, has been developed and validated. This article is one of the earliest studies utilizing this new instrument to determine the prevalence of moral distress in a community hospital setting.

Methodology

In this study, we distributed a self-administered, validated survey titled “Measure of Moral Distress—Healthcare Professionals”¹⁴ to all physicians and nurses at Raritan Bay Medical Center, Perth Amboy. Participants were presented with 27 scenarios and rated the frequency and intensity of distress they experience in each scenario on a scale of 1 to 4. The frequency and distress were multiplied (f × d) to provide subscores for each scenario ranging between 0 and 16. The 27 subscores’ summation produces a composite score ranging between 0 and 432, known as the MMD-HP score, for each respondent. The sum of frequency and distress was determined by adding the values of frequency and distress of the 27 scenarios. Two multiple-choice questions about the respondent’s desire to leave their position due to moral distress conclude the survey. The responses from these multiple-choice questions do not contribute to the MMD-HP score but were used to determine cutoffs for mild, moderate, and severe moral distress. The mean MMD-HP score of participants considering leaving their position was used as the boundary for severe moral distress and the mean MMD-HP score of participants not considering leaving their position as the boundary for mild moral distress.

The survey was distributed throughout the emergency room (ER), the medical/surgical ward, the telemetry ward, and the intensive care units (ICUs). The respondents returned the surveys in a locked box placed conveniently in each ward. After 2 weeks, the boxes were collected and responses were reviewed. Surveys with missing information were eliminated, and the de-identified information was entered into an Excel sheet before being uploaded to STATA 18 for further analysis. The research protocol was reviewed by Meridian Health Institutional Review Board (IRB) and determined to meet the exemption category because the information obtained by investigators could not be linked to subjects through any identifiers. Permission to use the MMD-HP survey was obtained from the authors. No interventions to specifically mitigate moral distress were performed before the administration of the survey.

Categorical variables were described by total count and percentage. For continuous variables, we determined the mean, range, and standard deviations (SDs). The mean composite scores of MMD-HP were compared using a two-sample t-test for dichotomous variables. For variables with greater than 2 groups, we used a one-way analysis of variance (ANOVA) to compare mean composite scores of MMD-HP.

Ethical considerations

The primary ethical concern in this study, was the potential leak of participant identifying information. No directly identifying information or information connecting a survey response to an individual was collected. After survey information was entered into an electronic database and statistical analysis was complete, the paper surveys were discarded in a locked shredding receptacle on hospital premises. This study was approved by the Raritan Bay Medical Center’s Institutional Review Board.

Results

A total of 119 surveys were collected from respondents, 18 surveys were excluded for missing information, and only 101 surveys remained in the study. There was a potential pool of 206 respondents (89 physicians, 154 nurses), with an overall 49.0% response rate (48.1% nurses, 30.3% physician). As shown in Table 1, the mean MMD-HP score for all respondents was 143.0 (SD = 79.8), and 35% of respondents considered leaving their position due to moral distress. The MMD-HP score for respondents not considering leaving their position due to moral distress was 94.7 (SD = 55.5), and the MMD-HP score for respondents considering leaving their position due to moral distress was 178.8 (SD = 76.5). Therefore, as shown in Table 2, the mean MMD-HP scores between 94.7 and 178.8 were defined as moderate and mild, respectively, and severe was defined as mean MMD-HP scores below and above the moderate range.

Table 1.

Mean frequency, distress, and MMD-HP score by gender, profession, ward, and considering leaving their position due to moral distress.

	Not Leaving		Leaving		Total
	N (%)	Mean (SD)	N (%)	Mean (SD)	N	Mean (SD)	p-value (95% CI)
Total
Mean MMD-HP score	58 (62)	94.7 (55.5)	35 (38)	178.8 (76.5)	101	143.0 (79.8)
Mean sum of frequency		37.0 (16.4)		56.7 (18.5)		48.3 (20.1)
Mean sum of distress		43.7 (18.6)		65.8 (17.7)		56.4 (21.1)
Male							p = 0.019^Ŧ(2.05 to 74.4)^Ŧ
Mean MMD-HP score	20 (77)	81.6 (43.8)	6 (23)	167.2 (98.2)	26	117.8 (82.4)
Mean sum of frequency		35.7 (11.7)		56.3 (23.6)		44.4 (20.2)
Mean sum of distress		40.3 (16.6)		59.4 (21.1)		48.4 (20.7)
Female
Mean MMD-HP score	35 (59)	103.3 (60.6)	28 (41)	184.2 (71.8)	69	156.0 (78.0)
Mean sum of frequency		36.9 (18.9)		57.3 (17.4)		50.2 (20.3)
Mean sum of distress		47.0 (18.7)		67.7 (16.9)		60.5 (20.0)
Physician							p = 0.001^◊(−102 to −36.1)^◊
Mean MMD-HP score	22 (81)	87.8 (38.4)	4 (15)	103.4 (35.0)	27	92.4 (37.4)
Mean sum of frequency		36.6 (9.3)		43.1 (9.08)		38.6 (9.5)
Mean sum of distress		42.8 (15.2)		47.5 (10.5)		44.2 (13.9)
Nurse
Mean MMD-HP score	36 (49)	100.3 (66.3)	31 (42)	190.9 (74.5)	74	161.5 (83.3)
Mean sum of frequency		37.3 (20.6)		58.9 (18.8)		51.8 (21.7)
Mean sum of distress		44.5 (21.3)		68.7 (16.9)		60.8 (21.5)
Medical/Surgical ward							p = 0.003^§(72.8 to 154.7)^§
Mean MMD-HP score	12 (80)	77.5 (59.6)	1 (7)	132.8 (76.6)	15	95.9 (68.5)
Mean sum of frequency		31.3 (15.6)		42.6 (18.6)		35.1 (16.9)
Mean sum of distress		35.8 (24.1)		67.8 (19.9		46.5 (27.0)
Telemetry
Mean MMD-HP score	12 (60)	151.6 (82.6)	7 (35)	213.0 (80.8)	20	197.7 (83.6)
Mean sum of frequency		53.4 (26.7)		65.3 (19.6)		62.4 (21.5)
Mean sum of distress		55.4 (13.5)		71.3 (19.0)		67.4 (18.8)
ICU
Mean MMD-HP score	11 (55)	95.6 (35.3)	5 (25)	194.7 (70.7)	20	160.0 (76.8)
Mean sum of frequency		34.9 (10.7)		61.0 (16.8)		51.9 (19.5)
Mean sum of distress		50.0 (13.9)		70.5 (16.9)		63.3 (18.5)
ER
Mean MMD-HP score	15 (54)	95.0 (58.8)	13 (46)	178.5 (66.7)	28	151.7 (74.6)
Mean sum of frequency		38.6 (19.2)		55.1 (17.1)		49.6 (19.2)
Mean sum of distress		44.2 (19.7)		64.0 (14.5)		57.6 (18.5)

CI: confidence interval; MMD-HP: Measure of Moral Distress—Healthcare Professionals; ER: emergency room; SD: standard deviation.

^Ŧp-value and 95% CI of mean MMD-HP scores between males and females.

^◊p-value and 95% CI of mean MMD-HP scores between nurses and physicians.

^§p-value and 95% CI of mean MMD-HP score among all departments.

Table 2.

Categorization of severity of MMD-HP.

	MMD-HP Score	N (%)
Mild	<94.74	34 (34)
Moderate	94.74–178.8	28 (27)
Severe	>178.8	39 (39)

MMD-HP: Measure of Moral Distress—Healthcare Professionals.

When comparing genders, females had a statistically significantly higher mean MMD-HP score than men (156.0 vs 117.8, respectively; p = .019), and more females considered leaving their position compared to men (41% vs 23%, respectively). The mean MMD-HP score was 1.75 times greater for nurses than for physicians (161.5 vs 92.5, p < .001), and nurses were 2.8 times more likely to consider leaving their position due to moral distress (42% vs 15%). The mean MMD-HP score for moral distress was the lowest in the medical/surgical ward (95.9, SD = 68.5) and the highest in the telemetry ward (197.7, SD = 83.6). The ICU ward had a mean MMD-HP score mildly greater than the ER (160.0, SD = 76.8 vs 151.7, SD 74.6, respectively). However, ER nurses were 1.84 times more likely than ICU nurses to consider leaving their position (46% vs 25%).

As shown in Table 3, physicians had the highest subscore (f × d) for scenario number 2 (6.07). Nurses had the greatest subscore for scenario number 16 (10.91), suggesting that all nurses commonly feel like they are taking care of more patients than they feel is safe. Telemetry nurses scored the highest for scenario 18 (13.76), scenario 16 (13.75), scenario 4 (11.25), and scenario 17 (10.80). ICU nurses scored the highest for scenario 2 (10.75), scenario 19 (10.40), and scenario 16 (10.15). ER nurses scored the highest for scenario 16 (11.00), similar to telemetry. The highest score on the medical/surgical floor was 7.00, corresponding with scenario 22.

Table 3.

Average subscores (frequency × distress) for each scenario by profession and ward.

	Scenario	Physician	Nurse	M/S*	Tel	ICU	ER
1	Witness healthcare providers giving “false hope” to a patient or family.	2.41	3.77	0.70	3.85	6.20	2.61
2	Follow the family’s insistence to continue aggressive treatment even though I believe it is not in the best interest of the patient.	6.07¹	7.67	4.20	9.05	10.75¹	6.11
3	Feel pressured to order or carry out orders for what I consider to be unnecessary or inappropriate tests and treatments.	4.44⁵	5.93	4.00	6.85	6.70	6.25
4	Be unable to provide optimal care due to pressures from administrators or insurers to reduce costs.	3.67	8.22⁴	4.60	11.25³	7.30	7.04
5	Continue to provide aggressive treatment for a person who is most likely to die regardless of this treatment when no one will make a decision to withdraw it.	4.07	6.43	4.60	7.20	9.45⁴	4.43
6	Be pressured to avoid taking action when I learn that a physician, nurse, or other team colleague has made a medical error and does not report it.	1.37	2.69	1.90	2.65	3.65	2.29
7	Be required to care for patients whom I do not feel qualified to care for.	1.33	3.84	2.40	6.50	3.30	2.43
8	Participate in care that causes unnecessary suffering or does not adequately relieve pain or symptoms.	2.41	4.96	1.80	7.60	5.80	3.43
9	Watch patient care suffer because of a lack of provider continuity.	4.56⁴	6.35	4.20	9.95⁵	5.85	4.93
10	Follow a physician’s or family member’s request not to discuss the patient’s prognosis with the patient/family.	2.52	5.20	4.70	5.85	6.20	4.25
11	Witness a violation of a standard of practice or a code of ethics and not feel sufficiently supported to report the violation.	2.37	2.99	1.40	3.95	3.45	2.93
12	Participate in care that I do not agree with but do so because of fears of litigation.	4.56⁴	3.47	3.50	3.95	4.10	3.61
13	Be required to work with other healthcare team members who are not as competent as patient care requires.	4.26	6.51	5.00⁵	6.25	4.25	8.18⁵
14	Witness low quality of patient care due to poor team communication.	4.30	6.41	4.90	8.40	5.20	6.39
15	Feel pressured to ignore situations in which patients have not been given adequate information to ensure informed consent.	2.07	5.05	5.80⁴	6.05	4.40	3.96
16	Be required to care for more patients than I can safely care for.	4.96³	10.91¹	6.90²	13.75²	10.15³	9.96²
17	Experience compromised patient care due to lack of resources/equipment/bed capacity.	4.19	8.97³	4.90	10.80⁴	6.20	11.00¹
18	Experience lack of administrative action or support for a problem that is compromising patient care.	3.63	9.01²	3.10	13.76¹	7.60⁵	9.29³
19	Have excessive documentation requirements that compromise patient care.	5.67²	8.88	6.40³	9.20	10.40²	7.82
20	Fear retribution if I speak up.	2.78	7.39	4.30	8.70	7.50	6.54
21	Feel unsafe/bullied amongst my own colleagues.	1.22	3.97	3.50	5.70	1.95	4.04
22	Be required to work with abusive patients/family members who are compromising quality of care.	4.96³	7.92⁵	7.00¹	8.65	7.60⁵	8.32⁴
23	Feel required to overemphasize tasks and productivity or quality measures at the expense of patient care.	4.26	5.95	3.40	6.00	5.35	7.54
24	Be required to care for patients who have unclear or inconsistent treatment plans or who lack goals of care.	4.37	6.22	3.60	7.35	6.50	5.61
25	Work within power hierarchies in teams, units, and my institution that compromise patient care.	2.56	4.65	3.40	6.20	3.65	4.50
26	Participate on a team that gives inconsistent messages to a patient/family.	1.89	4.19	3.40	5.55	3.60	3.39
27	Work with team members who do not treat vulnerable or stigmatized patients with dignity and respect.	1.52	3.95	3.00	4.05	2.90	4.86

1, 2, 3, 4, and 5 denote ranking of subscore for each scenario from first highest score to fifth highest score by column.

*M/S - Medical/Surgical

Physicians scored scenario 21 (1.22) the lowest, suggesting they are less affected by abuse from families. Overall, nurses scored scenario 6 the lowest (2.69). Telemetry and ER nurses also scored scenario 6 the lowest (2.65 and 2.29, respectively). The ICU nurses ranked scenario 21 the lowest (1.95). The lowest scoring scenario in the entire survey was scenario 1 (0.70) by medical/surgical nurses.

Discussion

We compared the degree of physicians’ and nurses’ moral distress across different hospital wards. In general, physicians are experiencing a significantly lower degree of moral distress in our community hospital than nurses. Also, nurses in the telemetry ward experience a significantly greater degree of moral distress than nurses in other wards.

Since critical care and ER nurses manage the most critically ill patients, it was expected they would experience the highest degree of moral distress. On the contrary, our findings suggest that telemetry nurses experience higher moral distress levels than their critical care and ER counterparts. A possible explanation may be related to the resources available in a ward compared to the acuity of patients that nurses are managing. Although critical care and ER nurses manage higher acuity patients, they also have greater resources and training. In contrast, telemetry nurses manage sicker patients than nurses in medical/surgical wards, with marginally greater resources. The composite scores provide further support to this theory, as telemetry nurses scored highest on scenarios related to lack of support and resources. Similar hospital-wide studies in other institutions will help clarify whether this phenomenon is due to factors specific to this hospital or whether this is inherent to telemetry nurses’ role.

This is one of the earliest studies employing the validated version of the MMD-HP. Most studies on moral distress, including Epstein’s¹⁴ study, which initially validated the MMD-HP survey, are performed in large academic centers, while our study is one of the few measuring moral distress in a community hospital.

The physicians’ MMD-HP scores in our study were similar to the physicians’ MMD-HP scores in the Epstein’s study. Therefore, it does not appear that the institution’s size plays a significant role in physician moral distress levels. Further studies of physicians in different settings are required to validate whether this consistency is intrinsic to the clinician’s role or whether other factors are influencing their moral distress levels.

Nurses in our community hospital had a greater MMD-HP score, 112.3 versus 156.04, than the Epstein study. The most notable differences between the two studies are the hospitals’ size and history of interventions. However, due to other differences between the institutions, which cannot be accounted for, it is difficult to account for the disparity. For example, larger institutions maintain a larger pool of nurses, specialists, fellows, and residents, who manage more clinically complex patients in specialized wards. This creates a different frontline healthcare dynamic from smaller community hospitals with less on-call resources and wards managing a greater variety of clinical conditions. Unfortunately, the Epstein study did not present their data stratified by ward, so it is unclear whether there was significant variation among nurse MMD-HP scores.

Although not validated in the Epstein study, we calculated the average sum of frequency and average sum of distress as a secondary outcome. As expected, both values were greater in the group considering leaving their position than those who were not. It is also noted that the average sum of distress was greater than the average sum of frequency in all subgroups.

As shown in Table 2, the cutoff between mild and moderate MMD-HP scores is determined by the average MMD-HP score of respondents not considering leaving their position. This study’s boundary (94.7) is similar to the boundary calculated in the Epstein study (94.3). The boundary between moderate and severe MMD-HP scores is determined by calculating the average MMD-HP score of those respondents considering leaving their position. This study’s boundary (178.8) is also similar to the cutoff in the Epstein study (168.4). Therefore, a comparison between the two studies shows consistent boundaries for mild, moderate, and severe moral distress designations.

Conclusion

This study provides insight into the level of moral distress in a community hospital setting. As measured by the MMD-HP questionnaire, moral distress continues to be higher among nurses compared to physicians. Interestingly, it appears to be highest among nurses in the telemetry ward than medical/surgical, ICU, or ER. Compared to larger institutions, nurses’ average MMD-HP scores were greater in this community hospital, while physicians’ MMD-HP scores were similar. No intervention for moral distress was performed before this study; therefore, this presents an opportunity to assess the impact of mitigations on moral distress in this community hospital by rechecking MMD-HP scores after an intervention.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Karim Bayanzay

References

Lancsar

Louviere

. Conducting discrete choice experiments to inform healthcare decision making. Pharmacoeconomics 2008; 26(8): 661–677.

Jameton

. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs 1993; 4(4): 542–551.

Browning

. CNE article: moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care 2013; 22(2): 143–151.

Pauly

Varcoe

Storch

, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573.

Johnson-Coyle

Opgenorth

Bellows

, et al. Moral distress and burnout among cardiovascular surgery intensive care unit healthcare professionals: a prospective cross-sectional survey. Can J Critic Care Nurs 2016; 27(4): 27–36.

Dodek

Wong

Norena

, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care 2016; 31(1): 178–182.

Whitehead

Herbertson

Hamric

, et al. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh 2015; 47(2): 117–125.

Delfrate

Ferrara

Spotti

, et al. Moral distress (MD) and burnout in mental health nurses: a multicenter survey. La Medicina de Lavoro 2018; 109(2): 97–109.

Meltzer

Huckabay

. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004; 13(3): 202–208.

10.

Piers

Van den Eynde

Steeman

, et al. End-of-life care of the geriatric patient and nurses’ moral distress. J Am Med Dir Assoc 2012; 13(1): 80.e7–80.e13.

11.

Hamric

Borchers

Epstein

. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Res 2012; 3(2): 1–9.

12.

Bruce

Miller

Zimmerman

. A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Crit Care Med 2015; 43(4): 823–831.

13.

Henrich

Dodek

Alden

, et al. Causes of moral distress in the intensive care unit: a qualitative study. J Crit Care 2016; 35: 57–62.

14.

Epstein

Whitehead

Prompahakul

, et al. Enhancing understanding of moral distress: the measure of moral distress for health care professionals. AJOB Empir Bioeth 2019; 10(2): 113–124.