Discussion:
This novel study evaluated moral distress among providers caring for
long term tracheostomy and ventilator dependent patients in a non-ICU
setting. Our results suggest that moral distress scores for providers
are similar in an inpatient unit caring for children with tracheostomy
and ventilator dependence compared to pediatric and neonatal ICUs
(4-6,8-9,12). There are similarities between ICU patients and non-ICU
tracheostomy dependent patients that may explain this. For example, it
is well known that caring for tracheostomy and ventilator dependent
children is expensive for both families and health care systems, have
high rates of readmission, are complicated by invasive procedures, can
entail discussions around goals of care or complex treatment plans, and
navigating the limited resources related to home healthcare (often
limiting discharge planning) (13-15). These complexities lead to long
hospital stays, and this may exacerbate moral distress in settings not
designed for long term acute care. Unlike non-hospital based long term
acute care facilities (LTAC), there are limitations to providing long
term care in the hospital setting. Often these patients are very
medically complex, limiting options that would normally mitigate
distress, such as planned outings, group activities, and predictable
schedules. In addition, patients with lengthy hospital stays of 1 year
or more can disrupt or cause bottlenecks in patient flow, placing
chronic systemic pressure on staff with respect to space and bed
availability.
One particularly novel finding in our study is the high rate of moral
distress experienced by APPs. This is likely attributable to a variety
of reasons. First, in the TCC, APPs do not rotate off service as often
as physicians (physicians cover between 2-6 weeks a year in the unit).
The APP’s are also responsible for a larger number of patients in the
unit than the RN/RTs, which each APP covering 6-10 patients each shift.
APPs thus provide a high degree of continuity for all patients in the
TCC, and are subjected to the stressors for every patient in the unit
for an extended period of time. This is contrasted to attending
physicians, who are subjected to stressors for every patient in the TCC,
but who rotate off service on a regular basis. RN/RTs, by contrast, are
subjected to stressors for extended periods, but care for a discrete
number of patients. While all groups surveyed experience moral distress,
our hypothesis is that both the amount of patient exposure and the
constancy of this exposure plays a role in the degree of moral distress
that is experienced by APPs (5,6, 16). Second, APPs are responsible for
much of the day-to-day care of patients with the premise of practice
autonomy, however, this impacted by inconsistencies in professional
equity from attending physician to attending physician. The tension
between a high degree of responsibility accompanied by a lack of, or
inconsistency in, professional equity may lead to moral distress and
burnout. (16-19).
Understanding moral distress is important due to the significant impact
it has on burnout and staff turnover (3,8-9, 20-26). In addition,
burnout is associated with poorer quality of care, and significant
expenses due to decreased clinical productivity and early retirement
(24-26). Anecdotally, this has been seen in the TCC, with low rates of
engagement among providers for leadership activity outside of clinical
work. Understanding factors that are associated with moral distress is
important to provide options to decrease distress. Current strategies
recommended by the literature focus on mitigating the intensity of
stressors, and include education programs, reflective writing,
debriefing meetings, and moral empowerment programs (27-28). While some
early results are promising, the evidence is unfortunately mixed on the
durability of such interventions, and more research is necessary. Our
results suggest that along with decreasing the intensity of stressors,
decreasing the time of exposure (rotating off service) to distressing
situations and better balancing provider authority and responsibility
may also be necessary.
Our study has limitations consistent with any survey research. First, a
survey is a single snapshot in time, and recent patient interactions may
have influenced providers with salient distressing situations to fill
out the survey at a higher rate than those who had lower levels of
distress (non-responder bias). Second, this study was carried out before
the COVID-19 pandemic, and this may skew results, as recent data
suggests that the worldwide pandemic may change the degree of moral
distress felt by providers (29). Third, about a year prior to this
study, a clinical psychologist (APB) was embedded within the unit to
deliver evidence-based psychological interventions to patients and
families to promote coping and functioning as well as to help support
staff with feelings of distress. Due to this, our rates of moral
distress may be lower than similar units without this support in place.
Despite these limitations, our study remains the first quantitative
examination of moral distress in a non-ICU caring for long term
tracheostomy/ventilator dependent patients.