ICU nurses' moral distress levels differ based on perceived use of palliative care

Critical care nurses may be less likely to experience moral distress when they feel that patients' palliative care needs are being met, according to new research in the October issue of Critical Care Nurse (CCN).

Palliative care focuses on enhancing the quality of life of seriously ill patients and their families, both during life-sustaining treatment and at the end of life when such treatment is no longer warranted. Yet, significant barriers to access to palliative care in intensive care units (ICUs) remain, including unrealistic expectations of treatment and insufficient education for clinicians.

The failure to relieve patients' suffering and feeling forced to provide aggressive interventions perceived as inappropriate or futile can trigger moral distress. Repeated exposure to these situations has been associated with burnout, compassion fatigue and intent to leave a nursing position or the profession altogether.

"Palliative Care and Moral Distress: An Institutional Survey of Critical Care Nurses" reports the findings of a survey of over 500 critical care nurses in seven critical care units at University of Virginia Medical Center, Charlottesville. A total of 167 questionnaires were included in the final analysis.

The survey used validated instruments to measure participants' perceptions of palliative care in their practice setting and their recent experiences of moral distress, exploring the relationships that may exist between the two.

Alexander Wolf, DNP, RN, APRN, CCRN, is a palliative care nurse practitioner at TriHealth in Cincinnati. As part of his doctoral studies at University of Virginia (UVA) School of Nursing, he worked with faculty from the UVA medical and nursing schools to conduct the survey.

This study confirms that moral distress is a common emotional experience among critical care nurses, and we found that moral distress levels differed significantly on the basis of perceived use of palliative care. The consequences of moral distress may have far-reaching effects on nurse well-being, as well as turnover and staffing, which may threaten patient safety and cause needless waste of valuable human and financial resources."

Alexander Wolf, palliative care nurse practitioner, TriHealth

The study found a high prevalence of moral distress among nurses during the period studied, particularly if they felt they were prolonging the dying process or when the goals of treatment were unclear. Consistent with other studies of nurses, physicians, and other healthcare providers, the study by Wolf et al. revealed a significant percentage of nurses who have considered leaving their position because of moral distress.

In addition, moral distress levels were highest among respondents who felt palliative care services were never used when indicated and lowest among those who reported that palliative care services were always used when indicated.

The results of this study add to our understanding that knowledge gaps and deficiencies in palliative care education exist for critical care nurses. For example, most respondents perceived each of the palliative care competencies as highly important, but fewer than 40% felt highly competent in any single competency. Of the 10 competency domains assessed, the team communication domain had the highest proportion of respondents self-rating as highly competent (38%), while only 11% of respondents rated themselves as highly competent in their knowledge of advance directives, living wills and do-not-resuscitate order.

Many critical care nurses do not feel prepared to provide palliative care, even though it has evolved into a key component of critical care and recommended by numerous professional critical care societies. Most respondents in this study had little palliative care education, with 38% reporting none in the past two years.

The well-known lack of palliative care education among critical care nurses denotes a need to increase access to palliative care continuing education and to assess education for new graduate nurses entering practice. The authors call for health system leaders and educators to prioritize palliative care education for critical care nurses and their interprofessional colleagues and empower them to reduce barriers to palliative care.

As the American Association of Critical-Care Nurses' bimonthly clinical practice journal for high-acuity and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.