Moral distress perspectives among interprofessional intensive care unit team members

Abstract

Aim:

To examine interprofessional healthcare professionals’ perceptions of triggers and root causes of moral distress.

Design:

Qualitative description of open-text comments written on the Moral Distress Scale–Revised survey.

Methods:

A subset of interprofessional providers from a parent study provided open-text comments that originated from four areas of the Moral Distress Scale–Revised, including the margins of the 21-item questionnaire, the designated open-text section, shared perceptions of team communication and dynamics affecting moral distress, and the section addressing an intent to leave a clinical position because of moral distress. Open-text comments were captured, coded, and divided into meaning units and themes using systematic text condensation.

Participants:

Twenty-eight of the 223 parent study participants completing the Moral Distress Scale– Revised shared comments on situations contributing to moral distress.

Results:

All 28 participants working in the four medical center intensive care units reported feelings of moral distress. Feelings of moral distress were associated with professional anguish over patient care decisions, team, and system-level factors. Professional-level contributors reflected clinician concerns of continuing life support measures perceived not in the patient’s best interest. Team and unit-level factors were related to poor communication, bullying, and a lack of collegial collaboration. System-level factors included clinicians feeling unsupported by senior administration and institutional culpability as a result of healthcare processes and system constraints impeding reliable patient care delivery.

Ethical Considerations:

Approval was obtained from the Institutional Review Board (IRB) of the University of Texas Health IRB and the organization in which the study was conducted.

Conclusion:

Moral distress was associated with feelings of anguish, professional intimidation, and organizational factors that impacted the delivery of ethically based patient care. Participants expressed a sense of awareness that they may experience ethical dilemmas as a consequence of the changing reality of providing healthcare within complex healthcare systems. Strategies to combat moral distress should target team and system interventions designed to improve interprofessional collaboration and support professional ethical values and moral commitments of all healthcare providers.

Introduction

Moral distress occurs when a healthcare professional experiences a conflict of knowing the ethically correct professional course of action but feels constrained from following through with the actions he or she deems to be “right” due to institutional, unit, interpersonal, or regulatory constraints and having limited power to change the situation.^1–3 Recently, this definition has been expanded to include seven key components, including collusion in wrongdoing, feelings of being voiceless, distress over not adhering to an established professional value, repeated clinical experiences that challenge the clinician’s ethical value system, and patient-centered concerns, team and unit factors, and organizational conflicts.^1,4–7 In the intensive care unit (ICU) setting, where complex care is delivered to critically ill patients, clinician moral distress is a significant issue. In this setting, strong professional disagreements relating to care decisions among interprofessional team members may impact healthcare providers’ perceptions of the most beneficial treatment to implement. Healthcare providers’ professional ethical beliefs may be at odds with the care being proposed by colleagues due to team members having differing professional value systems.⁸ These differences in professional values may prompt conflicts to erupt as teams attempt to reach a consensus on the most beneficial plan of care. These active conflicts may negatively impact team function and may contribute to adverse patient outcomes as team dynamics and communication deteriorate.⁹ The net result of these professional conflicts can leave the clinician feeling coerced to act unethically, setting moral distress in motion.¹⁰ To better address the triggers and root causes of moral distress, we must first understand the professional perspectives of healthcare professionals providing care.

Background

Healthcare professionals are at risk of moral distress due to the proximity, frequency, and sustained time they spend caring for patients with life-limiting conditions that may be at odds with their professional ethical beliefs. Until recently, few studies have shared the written-in clinician perspectives provided on the Moral Distress Scale–Revised (MDS-R) indicating the core contributing factors initiating feelings of moral distress. An effort to examine perspectives not captured by the standard measures of moral distress was undertaken by Epstein et al.¹⁰ Their study identified core factors including patient-centered care conflicts, clinical setting or unit dynamics, and system constraints that contributed to moral distress development by combining data from 22 previous studies and examining 301 write-in participant comments included on the MDS-R survey. Of these core write-in comments on the MDS-R survey, providers frequently rated participating in non-beneficial treatments, ethical conflicts with colleagues, lack of shared decision-making, team discordance, and poor team communication as causing them the most moral distress.^5,11 Healthcare professionals in these studies perceived that when team communication failed, clinicians experienced professional burnout and patients were more likely to experience poorer outcomes and lasting harm due to errors in patient care.^11,12 The aim of this descriptive study was to examine write-in text comments sharing perceptions of interprofessionals regarding the triggers and root causes of moral distress among interprofessional healthcare providers.

Methods

This qualitative descriptive study of participants’ write-in text comments sharing perceptions of triggers and root causes of moral distress on a paper MDS-R survey is a sub-study of the parent study conducted among four interprofessional ICUs at a single medical center hospital. The quantitative findings of the parent study were previously discussed in an article currently under review. This article will focus more on the written-in comments participants shared on the MDS-R survey. Participants’ perceptions were extracted from four sections of the MDS-R. Write-in comments originated from the margins of specific MDS-R questions, the designated survey section asking “If there are other situations in which you have felt moral distress, please write them and score them here” and shared perceptions of two additional scaled questions added to the MDS-R to better understand the influence of team communication and dynamics affecting moral distress asking “Team dynamics has affected my level of moral distress” and “Team communication has affected my level of moral distress.” The survey section also addressed intent to leave a clinical position because of moral distress with the way patient care was handled. Institutional review board (IRB) approval was obtained from the IRBs of the University of Texas Health IRB and the organization in which the study was conducted.

Ethical Considerations

Approval was obtained from the Institutional Review Board (IRB) of the University of Texas Health IRB and the organization in which the study was conducted. Eligible RNs and APRNs, social workers, respiratory therapists, and clergy were recruited by in-person presentations before morning and evening shift reports and during monthly unit meetings. Prior to beginning the survey, participants were provided an IRB approved information sheet explaining the purpose of the research, voluntary nature of participation, and measures taken to ensure respondent confidentiality. Demographic and MDS-R survey results were collected and imported into a secure computer excel spread sheet managed by the researcher. Participants were advised that their individual responses and identity would remain confidential. Participants were further advised that their survey responses would not be shared with department supervisors or be used in any performance evaluations. Healthcare professionals provided their consent for the study by completing the MDS-R and demographic survey.

Setting and sample

This sub-study was conducted between November and December 2017 at a large hospital in the southwest. Participants were included if they wrote in text comments on the parent study paper of MDS-R survey administered to interprofessionals providing care to patients in the Medical ICU, Trauma ICU, Pediatric ICU, and Neonatal ICU at a single hospital. The parent study and sub-study included seven professional roles functioning as a cohesive team determined by in-person interviews with registered nurses (RNs), advanced registered nurses (APRNs), physicians, respiratory therapists, social workers, clergy, dieticians, unit leadership, and department administrators.

Participants

In all, 28 of the 223 healthcare professionals completing the parent study demographic and MDS-R surveys were included as a result of providing write-in text comments. Parent study RNs and APRNs, physicians, social workers, respiratory therapists, dieticians, and clergy were recruited by in-person presentations before morning and evening shift reports and during monthly service line or unit meetings. Participants from each of the seven professional roles recruited by the parent study provided write-in text comments sharing perceptions on situations causing them moral distress. The sample included 15 RNs, 1 APRN, 4 physicians, 1 social worker, 2 respiratory therapists, 4 clergy, and 1 dietician.

Instruments

Demographic data

Participants’ age, education level, professional role, and years of ICU experience were extracted from the parent study demographic survey. Descriptive statistics of participants’ demographics were extracted from the parent study (see Table 1).

Table 1.

Participant demographics and MDS-R scores.

Role (n)	MDS-R (± SD), range	Unit (n), MDS-R (± SD), range	Age	Years of experience in the ICU	Highest education
RN (n = 15)	93.60 (55.08), 3–229	MICU (n = 5), 66.40 (47.30), 31–143	20–27 (n = 4)	1–5 (n = 9)	Bachelor (n = 16)
Physician (n = 4)	114.25 (62.75), 44–191	TICU (n = 7), 120 (36.36), 78–191	28–35 (n = 7)	6–10 (n = 5)	Master (n = 8)
Respiratory therapist (n = 2)	60.50 (28.99), 40–81	PICU (n = 6), 74.50 (46.90), 20–140	36–41 (n = 3)	11–15 (n = 6)	Doctorate (n = 4)
Clergy (n = 4)	56.25 (38.69), 20–105	NICU (n = 10), 75 (61.03). 3–229	42–46 (n = 6)	16–20 (n = 3)
APRN (n = 1)	78		47–53 (n = 6)	21–25 (n = 2)
Social worker (n = 1)	64		54–60 (n = 2)	26–30 (n = 3)
Dietician (n = 1)	20

MDS-R: Moral Distress Scale-Revised; SD: standard deviation; ICU; intensive care unit; MICU: medical intensive care unit; TICU: trauma intensive care unit; PICU; pediatric intensive care unit; NICU: neonatal intensive care unit.

The term “RN” includes registered nurses. The term APRN includes advanced practice registered nurses. The term “Physician” includes attendings, fellows, and residents. MDS-R scores are reported in mean.

MDS-R

The 21-item MDS-R survey developed by Hamric, Borchers, and Epstein2 was used on the parent study to measure moral distress using six parallel versions for adult and pediatric RNs, physicians, and other healthcare providers. The MDS-R is a 21-item survey that examines clinical situations thought to cause moral distress and calculates a moral distress score based on participants’ responses to the survey questions. The MDS-R survey allows for write-in text in the survey question margin and in a designated section of the MDS-R. The parent study added two additional items to determine the participants’ perspective on the role of team dynamics and poor communication in the development of moral distress. The 21-item MDS-R survey has been tested for content validity and is well established and scientifically accepted as a reliable tool to measure moral distress in RNs, physicians, and other healthcare professionals.²

Analysis

The study adopted a descriptive qualitative design to address the study aims by using participants’ write-in text comments written in the question margins and on the open-ended text field of the MDSR survey asking, “If there are other situations in which you have felt moral distress, please write them and score them here.” Participants’ write-in text comments from the MDS-R surveys were exported directly into an Excel spreadsheet to capture participants’ perceptions of situations causing them moral distress. Write-in texts were analyzed inductively using systematic text condensation (STC).¹³ STC was used to develop a pragmatic approach to thematic analysis of written texts to gain understanding of qualitative experiences shared by participants. In step 1, all text comments provided were read several times to gain a total impression of the patterns of experiences shared by participants and to identify emerging themes. In step 2, meaning units were identified and sorted into code categories. In step 3, the meaning units within each code category were condensed into subcategories (see Table 2). Finally, the texts were synthesized from categorical patterns of the shared perception to descriptions and conceptual themes (see Table 3).

Table 2.

Illustration of the analysis process.

Category	Subcategory	Meaning units	Condensate
Professional concerns related to care practices in the ICU environment	Concern over participation in futile care	I have witnessed the medical team follow the family’s wishes to continue life support and initiate extensive lifesaving actions when I think they only prolong death Keeping a patient in ICU with no chance of survival and letting them continue with a means of medicine that is not therapeutic causes me moral distress. The reality of healthcare is that we initiate lifesaving treatment that prolongs death—that is what often happens in hospitals I frequently dread going into work due to feeling morally distressed	Concern over continuation of non-beneficial life support Inappropriate use of ICU resources Initiation of aggressive lifesaving measures delaying death Motivation to work is reduced due to overtreatment of patient practices

ICU: intensive care unit.

Table 3.

Overview of categories and subcategories.

Categories	Subcategories
Professional concerns related to care practices in the ICU environment	Concern over participation in futile care
	Family member wishes drive non-beneficial care decisions
	ICU placement to continue non-therapeutic treatment
	How healthcare providers are affected by continuing lifesaving measures that represent futile care
	Fear of tarnishing professional image among peers
	Perceived role conflicts
	Significance of critical care setting stressors
	Abuse by patient family members
	Restrictions related to HIV status disclosure
	Loss of motivation to carry out work duties due to patients’ overtreatment concerns
Team/Unit behavior concerns	Professional bullying by superiors
	Professional burden experienced when the patient treatment plan is poorly communicated
	Lack of informed consent by providers
	DNR treatment inconsistencies among clinicians
	Inconsistencies in provider preparation
	Failure to inform and collaborate with team members
	Demeaning behaviors among interprofessional team members
System concerns perceived to diminish patient care and reduce staff empowerment	Nurses’ concerns related to floating to other units outside of specialty setting
	Failure by leadership to gain stakeholder perspective
	Challenges presented by patient language barriers
	Unbalanced task ratio per nurse
	Staffing shortages

ICU: intensive care unit; DNR: Do-Not-Resuscitate.

Results

Over 10% of the parent study participants shared professional perspectives on triggers and root causes of moral distress. A total of 35 comments were written in by 28 participants from the varying professional roles. Of the 35 comments, 10 comments were written in the margins of the 21 clinical scenarios on the MDS-R survey. Seventeen comments were written in the designated section of the survey which stated, “If there are other situations in which you have felt moral distress, please write them and score them here.” Four participants left comments on the MDS-R survey asking, “Have you ever left or considered quitting a clinical position because of your moral distress with the way patient care was handled at your institution?” One participant commented on the inquiry of team dynamics affecting moral distress asking, “Team dynamics has affected my level of moral distress,” and three participants commented on the question asking, “Team communication has affected my level of moral distress.”

These write-in texts expand the understanding of situations contributing to moral distress by identifying clinician concerns related to ethical issues that are either poorly understood by healthcare professionals or not previously captured by a moral distress tool. The shared participants’ perspectives in this study expand on the key components recently identified as causing significant moral distress.^10,14 These shared perspectives demonstrate the central factors impacting moral distress development that influence professional satisfaction. These factors relate to patient care decisions, unit and team dynamics, and system-level concerns. The text comments provided by participants in this study confirm that end-of-life care decisions and concerns related to aggressive therapy aimed at saving a patient’s life significantly contribute to moral distress regardless of professional role, clinical setting, or duration of time spent at the bedside. Participants’ write-in texts can be grouped according to patient care decisions, unit and team-level factors, and system level factors.

Patient care decisions

The shared perceptions of interprofessional healthcare providers involving patient-centered causes of moral distress draw attention to professional concerns regarding continuing life support and prolonging the outcome of death. One RN considered continuing futile care “due to parent wishes” as a factor in their moral distress development. Another RN shared that the reality of healthcare is that we initiate lifesaving treatment that prolongs death, “that’s what often happens in hospitals” and reflected that “family members are usually the ones who default in making a decision.” Clinical participants shared professional concerns regarding a lack of disclosure of HIV status of patients or children to at-risk family members. Participants shared that they experienced moral distress when they were abused by aggressive family members. An RN stated she often experienced abuse by families “demanding patient care the clinical team deemed not in the patient’s best interest and non-beneficial.” Societal concerns impacting moral distress development were expressed by participants. An RN shared that caring for vulnerable populations with significant language barriers complicated end-of-life care delivery. The RN stated that “taking care of illegals and people who refuse to speak English near the end-of-life” contributed to his or her moral distress. Clergy members of the adult and pediatric teams also shared their perspectives on patient-level factors leading to feelings of moral distress. One adult clergy member revealed feeling morally distressed when he or she was caring for patients implicated in a crime that caused another to be critically injured. The clergy admitted feeling moral distress “when I am actively providing emotional and spiritual care to patients implicated in the abuse of others.” The overall theme identified by participants’ text comments indicates a feeling of professional anguish related to active and passive participation in end-of-life care decisions as a process of determining the most appropriate care to implement in critically ill patients.

Unit and team factors

Participants voiced unit and team-level factors influencing their level of moral distress. Issues of team dynamics, a lack of collegial collaboration with medical consults, poor communication, and professional knowledge deficits contributed to moral distress. Comments related to feeling a lack of collegial respect and poor collaboration were evident over all professional roles. A dynamic of intimidation and bullying by colleagues was shared by multiple participants. An RN stated, “the team failed to initiate an ethics consultation due to fearfulness of an attending physician’s response to the requested consultation.” Another RN shared that respect among professionals was a key issue for considering leaving a current position. The RN wrote, I am considering leaving my current position due to the staff/doc relations. I feel that the physician leadership has very little to no respect for the nursing staff. The behavior that is displayed by some of the doctors would NEVER be tolerated if the tables were turned.

Poor communication and team dynamics contributed to perceptions of moral distress. A respiratory therapist shared that “team communication has affected my level of moral distress when physicians make vent changes without consulting Respiratory and no order is placed.” A social worker shared that they felt “professionally burdened when watching patient care suffer because the team cannot get on the same page regarding what’s best for the patient.” Some clinicians attributed their moral distress to variations in staff preparedness during patient rounds and poor team communication, while another participant shared feeling moral distress due to pressures from superiors to order unnecessary tests. Differences in professional behavior related to appropriate patient care was identified as a significant situation causing moral distress. The source of these feelings was experienced either through conflicting treatment of a patient with a Do Not-Resuscitate order or physicians failing to provide realistic prognosis information to families. One physician shared that “Providers who act like ‘DNR’ means DO NOT TREAT” contributed to his or her moral distress development. An RN shared that feelings of moral distress arose when there was a concern regarding the initiation of non-beneficial therapy, stating, “Keeping a patient in the ICU with no chance of survival and letting them continue with a means of medicine that is not therapeutic.”

The impact of team and unit factors contributing to moral distress was shared by a physician stating, “I am not considering leaving my position now, but I frequently dread going into work due to these kinds of morally distressing issues.” One clergy in the pediatric setting felt fearful and morally distressed when team members perceive them as approving abortion. A physician shared the perspective that his or her “moral distress feelings occurred due to personal knowledge deficiencies while caring for critically ill patients.” When this provider asked for help, he or she was judged harshly by their supervisors for his or her lack of expertise. Nurse participants shared perceptions on how they balance team and unit factors contributing to their moral distress. The overall theme of these shared perceptions is a feeling of professional distress experienced during interactions with co-workers due to dysfunctional interprofessional behaviors including intimidation, bullying, and a lack of provider collaboration and patient advocacy. In contrast to this theme, one RN participant shared that these factors led to no intention to leave his or her current position due to situations causing moral distress and shared that “the occasional moral distress experience has not occurred frequently enough to consider leaving.” The RN making this comment reported feeling higher moral distress compared to other RN participants in her clinical setting. Another RN participant expressed a similar perspective by acknowledging an understanding that moral distress situations were known and expected in an academic medical center setting by writing, “I LOVE my job and the people I work with. The stressors are a part of the job and this is a teaching hospital.” This RN reported lower moral distress compared to other RN participants in similar clinical settings.

System-level factors

System-level factors perceived to cause feelings of moral distress included clinicians feeling unsupported by individuals in a leadership role. An RN participant voiced system-level factors impacting moral distress development, stating, “My moral distress is caused when nursing administration sits in meetings and does NOT get bedside nurses’ perspective, but think they do.” Several RN participants identified staffing-related issues as the source of their moral distress. An RN acknowledged feeling moral distress “when I am required to care for patients I don’t feel qualified to care for as a result of being floated to an unfamiliar clinical unit.” Other factors RNs identified as causing moral distress included “feeling unprepared to care for patients from unfamiliar units due to inadequate staffing.” One participant shared that “new staffing from other hospitals are not competent which causes staff additional stress.” Other RNs identified “unsafe staffing” and being responsible for “too many tasks per nurse care ratio” as contributing to their moral distress. Participants also voiced that the inappropriate utilization of ICU beds, shrinking hospital resources, and concerning practices regarding solicitation of organ donation by outside agencies were issues that prompted feelings of moral distress. The overall theme of these shared perceptions is institutional culpability as a result of healthcare processes and system constraints impeding reliable patient care delivery.

Factors decreasing moral distress

Participants shared helpful measures to reduce moral distress in the critical care environment where patients often experience medical setbacks, disease progression, complications, and unexpected changes in vital signs. To alleviate moral distress, a physician found that “debriefing after a code is very helpful in avoiding distress.” Team dynamics and communication comments shared by participants represent the majority opinion of participants who “strongly agreed” or “agreed” that team dynamics and team communication affected their level of moral distress. Physicians and respiratory therapists shared their opinions on the importance of team communication and dynamics offering “good teams decrease moral distress” and “good team communication decreases moral distress.”

Discussion

This study expands on the common clinical situations identified in the 21-item MDS-R survey by addressing additional factors that healthcare professionals perceive as promoting moral distress. Similar to other studies, all participants reported experiencing moral distress.^4,6,9,11,12 The opportunity to hear the voice of the provider through their written-in comments sheds light on the limitations of the numerical aspects of the MDS-R to capture nuanced ethical situations that clinicians are confronted with in the course of delivering care to critically ill patients. The open-ended comments written in by participants bring to the forefront the challenging professional issues many clinicians face. Similar to the findings by Hamric and Epstein,^10,14 participants shared clinical situations related to a lack of voice, active involvement with aggressive care they deemed not resulting in measurable benefit to the patient, perceived coercion from supervisors to act in a manner not aligning with their professional values, poor team dynamics, and system constraints as contributing to feelings of moral distress.

This study provided participants a platform to share their perspective and voice. This study found that members from all professional roles experienced unique situations contributing to moral distress. The take away lessons from this study were that when clinician’s professional values were constrained due to patient, team, and system factors, they experience moral distress. Several participants recognized that many of the situations contributing to their moral distress were an aspect of being a healthcare professional. The majority acknowledge this; however, some participants seemed to expect these challenges when caring for critically ill patients in a fast-paced environment. These participants did not indicate that they were considering leaving their current positions as a result of situations they recognized as contributing to moral distress.

Perspectives shared by participants call attention to the expanded root causes of clinician moral distress that threaten professional integrity in three main domains: patient-centered issues, team and unit factors, and organizational conflicts. These dominant components relate to healthcare providers’ perceptions that they are colluding in wrongdoing either by omission or by commission of patient-centered disputes, feeling voiceless and unsupported by leadership, perceived distress over failing to adhere to professional values, and the burden of experiencing repeated challenges to their professional value system.^1,4,15 Similar to recent studies, participants voiced concerns when it seemed untenable to comply with their professional standards.^16,17 Healthcare providers shared feeling morally distressed when participating in patient-centered treatment they deemed inappropriate or non-beneficial or when patients or families were not told the necessary facts to make an informed decision regarding the continuation of heroic measures.

Our study found that some ICU team members experienced moral distress triggers involving patient centered issues (abusive family members demanding care deemed unbeneficial and continuing aggressive therapy not believed to improve the patient’s outcome), team and unit factors (bullying, intimidation, poor communication, and team discordance), and organizational conflicts (lack of hospital resources, inappropriate use of ICU beds, being voiceless, and staffing challenges that cause clinicians to care for patients they do not feel qualified to care for) that are similar to a recent study developing a new moral distress tool, the Measure of Moral Distress for Health Professionals (MMD-HP).¹⁰ According to Epstein et al.,¹⁰ when clinician concerns and opinions are either ignored or dismissed by system administrators or high-level leadership, they experience moral distress. Epstein opines that critical care clinicians possessing a wealth of expertise and unique insight as to the most appropriate care that patients require are constrained by system level factors preventing them from carrying out what they deem as the most appropriate patient care.

Participants’ write-in comments were consistent with recent rankings of clinical situations causing the most moral distress.¹¹ These situations include patient and team factors related to initiating or continuing life support measures not in the patient’s best interest or promoting a successful outcome, giving false hope to patients or family, patient suffering due to a lack of provider continuity, and issues related to poor team dynamics and communication, which were identified as the situations causing the most moral distress. Vincent et al.⁹ Some perspectives shared by participants in this study were previously unreported. These new perspectives represent the challenges that healthcare providers face in an ever-changing medical landscape with vulnerable patient populations. Written-in text comments demonstrate that providers experience moral distress when carrying out their professional standards is unachievable. For example, participants perceived moral distress when providing care to illegal immigrants, victims of violent crimes and their potential offender, and organ donation practices. This professional misalignment of values and care provided trigger feelings of moral distress. By hearing the voice of the healthcare provider, we can better address what is happening in clinical settings among healthcare teams not previously considered by the 21-item MDS-R survey. These unique participant perceptions merit additional study. Inclusion of these perspectives in a future tool may provide successful interventions to reduce clinician moral distress. Shared participant perspectives suggest that future approaches should incorporate team-building strategies, debriefing during critical situations, and improving team function.

Limitations

A limitation of this study is sampling bias from including study participants who self-selected to provide perspectives from two adult and two pediatric ICUs from a single hospital as well as a low number of responses provided by participants given the overall participation rate. Participants from dietary, clergy, and social work made up a small portion of the sample, and their perceptions may not align or reflect the opinions of other professionals within or outside of the participant role. The potential for response bias is known in studies relying on survey instruments to collect data.

Conclusion

The interprofessionals providing write-in text comments perceived that they experienced moral distress as a result of care practices occurring in the ICU environment that resulted in patient care they deemed aggressive or non-beneficial given the patient’s anticipated outcome. Although multiple clinical roles provided write-in text comments, clinicians overwhelmingly shared a perspective that healthcare providers should not engage in overtreatment of patients with a poor prospect of a meaningful recovery. Perceived poor team dynamics, bullying by superiors and peers, and a lack of professional collaboration triggered feelings of moral distress and influenced their desire to leave a position. Although some clinicians disagreed on what triggered their moral distress, most provided the perspective that their moral distress was a consequence of their practice environment including patient care decisions, team and unit dynamics, or system factors that created barriers in providing safe patient care. Other participants expressed that challenging situations and demanding circumstances were to be expected in an academic hospital setting and were to be expected as a result of healthcare within complex systems. New insight into the need for debriefing after experiencing highly stressful situations was suggested to reduce moral distress. Participants acknowledged that healthy team dynamics and supportive team communication were key factors that impacted their feelings of moral distress.

Implications for future research

This study demonstrates new perspectives shared by healthcare professionals related to perceived triggers and root causes of moral distress. The shared perspectives should guide future research aimed at exploring the root causes of moral distress in all clinical settings. There is a critical need for a qualitative study to better understand the issues of moral distress among different providers to operationalize interventions aimed at preventing moral distress or reducing the long-term effects healthcare providers experience when faced with pressures to act unethically.