Moral distress among critical care clinicians: Protective factors and consequences on clinicians’ well-being and quality of care

Introduction. Psychological well-being of people working in the helping professions has received increased attention in the last decade. Working in critical care settings, such as Intensive Care Units (ICUs), is especially stressful as it exposes clinicians to high patient morbidity and mortality, challenging work routines, and regular encounters with traumatic and ethical issues. Growing literature highlights that the experience of moral distress, that means not acting accordingly to what one perceives to be ethically right, is relevant among clinicians working in critical care. However, there is a lack of quantitative studies aimed to identify the protective factors and the consequences of moral distress on clinicians and patients. This thesis aimed to fill this gap by exploring: 1) the dimensionality of the construct of moral distress, through the validation of a scale to measure moral distress in Italy; 2) the protective factors of moral distress and its effect on clinicians’ psychological well-being; and 3) the relationship between clinicians’ moral distress and the perception of care quality by family members of ICU patients. Methods. A cross-sectional study was conducted involving physicians, nurses, and residents working in ICU, and the family members of their patients. Clinicians working in 8 ICUs (n=184) were administered the Moral Distress Scale-Revised (MDS-R; Hamric et al., 2012) and the Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 2006) for validation. In addition, a subsample of clinicians of 7 ICUs (n=170) were administered two further subscales (Value and Control) of the Areas of Worklife Scale (AWS; Leiter & Maslach, 2005) in order to assess the relationships between moral distress, value congruence, control and depression. Family members (n=59) of the patients hospitalized in a subsample of 5 ICUSs were administered the Family Satisfaction with care in the ICU survey (FS-ICU; Wall et al., 2007) in order to assess the relationship between clinicians’ moral distress and family satisfaction with care. Results. The Italian MDS-R showed a 4-factor structure composed of: Futile care, Poor teamwork, Deceptive communication, and Ethical Misconduct. This model accounted for 59% of the total variance and presented a good fit with the data (RMSEA=.06; CFI=.95; TLI=.94; WRMR=.65). For what concerns the protective factors of moral distress and its effect on clinicians’ well-being, a mediation path from value congruence and control to depression through moral distress was tested, yielding a significant total indirect effect of value congruence on depression through moral distress (β= -.12; p= .02). Regarding the effect of moral distress on the quality of care, moral distress of clinicians correlated with the family satisfaction as to the inclusion in the decision making process (ρ=-.900; p=.037). Moral distress of physicians and nurses correlated with different aspects of family members’ satisfaction. Conclusions. Findings of this thesis contributed to the refinement of the construct of moral distress and provided evidence of its multidimensionality. Congruence between individual and organizational value was found to influence moral distress. As moral distress was related to depression and family perception of care quality, interventions should be implemented to reduce it. The findings of this thesis offer a preliminary base for the development of tailored interventions for clinicians.