This is the largest study of moral distress in the UK to date and the first to use a multi-centre approach with assessment across ICU professions. Included ICUs were at both district general and teaching hospitals and were of varying size and sub-specialty capability. Moral distress was widespread across included sites and across ICU professions. Moral distress scores were highest in situations related to delivering aggressive treatment that was perceived as futile or not in the patient’s best interests, closely followed by lack of resources compromising delivered care. Moral distress was significantly worse in nurses and was not influenced by age or years of ICU experience. There was, as expected, a strong association between higher moral distress scores and intention to leave their current post. There was also a significant relationship between moral distress and leaving a previous post. These associations persisted in adjusted analyses and underlines the impact moral distress may have on ICU staff retention. It is concerning that one third of participants reported an intention to leave their current post due to moral distress. This study took place before the COVID-19 pandemic and it is possible the immense pressures on UK ICU services has impacted the experience of moral distress. This should be recognised when considering how this study reflects the current welfare of UK ICU professionals.
This is the first published use of the most up to date quantitative measure of moral distress (MMD-HP) in a UK healthcare setting.(35) Free text scenarios distinct from MMD-HP items were rarely described. Our study also included a qualitative assessment by semi-structured interviews (data presented elsewhere) and no interview participant described scenarios distinct from the MMD-HP items. With this in mind and considering the inclusion of a range of ICU professions and participants from multiple ICUs of different size and sub-specialty, this study gives support for use of the MMD-HP in UK research.
The only other quantitative study of moral distress in UK ICUs to date also found moral distress was significantly associated with an intention to leave a post, a finding consistent with international literature.(15, 21, 33, 36) It is increasingly clear that the impact of moral distress appears damaging to staff retention and should be considered by employers.(11, 15) Colville et al. were unable to detect a difference in moral distress scores between nurses and doctors and highlight the confounding impact of gender differences. Our larger study found that moral distress in greater in nurses and this difference remained statistically significant after accounting for differences in gender distributions. This finding is consistent with international study showing that nurses report greater moral distress than doctors.(21, 35, 36) This could be due to differences in ability to influence decision-making, lack of clinical information sharing between colleagues, and practical differences in how direct clinical care is delivered.(15) Lack of agency has been cited as a driver of moral distress; a phenomenon that may not occur equally between professions.(16) The difference between ICU professions in moral distress and intention to leave the profession should be reflected upon when considering delivery of possible interventions to alleviate moral distress. It is also notable that nurses had a significantly greater intention to leave the profession, including in adjusted analyses. Indeed, 37% of nurses included in our study indicated they were considering leaving their current post due to moral distress, compared with 15% of doctors, a concerning finding that potentially has staff retention and workplace planning implications.
There was a signal toward increased moral distress at larger tertiary care hospitals compared to district general hospitals, however this did not reach statistical significance. If there is a true difference this could reflect differences in clinical case-mix between units or could be due to differences in team size impacting staff wellbeing and ability to cope with moral distress. This finding deserves further investigation, particularly given possible future changes to the provision of UK critical care services toward larger units on a hub-and-spoke model.(37)
No correlation was found between ICU experience and moral distress score, therefore not lending support to the crescendo effect or the concept of moral residue.(38) The crescendo effect was proposed to explain the phenomenon of increasing moral distress after repeated exposure to similar situations, and it may be linked with formation of moral residue after a distressing event.(15, 19, 38) Not all moral distress research has demonstrated the crescendo effect or moral residue.(33, 36) Failure to capture the crescendo effect could be a result of study selection bias. It is increasingly clear that moral distress is associated with an intention to leave the profession, therefore those experiencing a crescendo effect may leave the profession and consequently not be included in snapshot studies. To empirically demonstrate the crescendo effect, longitudinal studies would be required.
Overall moral distress scores were higher in our study than similar research in the USA.(35) Mean moral distress scores were higher in our study across all profession subgroups.(35) At present, there is no other international use of this most up to date quantitative moral distress measure (the MMD-HP) to make further comparisons. Past studies have used the previous version (the Moral Distress Scale – Revised) which uses 21 items, compared with the MMD-HP’s 27, therefore precluding direct comparison. A recent study in Ireland during the COVID-19 pandemic does use the MMD-HP, but only selected items and so overall comparisons cannot be made.(39) Almost all highly ranked individual item composite scores were higher in our study than that in the USA.(35) This was most notable for resource-related items, specifically compromised care due to lack of resources/equipment/bed capacity, where the composite moral distress score was substantially higher in our UK study. This was ranked the second highest item by moral distress score in our study for both doctors and nurses, but ranked fifth in a comparative study in the USA.(35) This could reflect differences in healthcare delivery and the provision of critical care beds.(30–32) This high signal of moral distress raises a worrying concern that sub-optimal care may be being delivered due to resource constraints. This study is unable to determine if this is occurring, nevertheless the high levels of moral distress due to resource-related issues should be noted.
Whilst this research has focussed on intensive care practice, it seems unlikely that moral distress is a unique experience to the intensive care speciality. This study has shown moral distress occurs across healthcare professions within intensive care and across multiple ICUs. For example, moral distress may occur when healthcare professionals refer patients to intensive care, particularly if these patients are not admitted to the ICU; an area that remains unstudied. Future study in other clinical specialties appears prudent given the damaging nature of moral distress.
Our study has several limitations. Firstly, the study is at risk of selection bias. Those experiencing high levels of moral distress may be unwilling to complete the questionnaire, or alternatively those with low levels of moral distress may not appreciate its value and not take part. We only included those currently working in ICU and so cannot capture those that may have left ICU due to high levels of moral distress. We attempted to improve external validity by including multiple ICUs which had different operational characteristics. Secondly, there are more nurses than other professions in our sample, however this reflects the distribution of ICU professions.(22) Thirdly, this study is a snapshot and may be influenced by how the participant is feeling at that time, or what clinical cases are present on their unit. Moral distress may be a reactive process and be influenced by experiences at that point in time.(40) It is possible that moral distress may fluctuate and change as the clinical case-mix within an ICU changes. It remains unknown how moral distress changes over time and further study is warranted.