Moral Distress of Clinicians in Canadian Pediatric and Neonatal ICUs

Pediatr Crit Care Med. 2020 Apr;21(4):314-323. doi: 10.1097/PCC.0000000000002189.


Objective: To quantify moral distress in neonatal ICU and PICU clinicians and to identify associated factors.

Design: A national cross-sectional survey of clinicians working in an neonatal ICU or PICU. Moral distress was assessed with the Moral Distress Scale-Revised and by self-rating. Depersonalization was assessed on the subscale of the Maslach Burnout Inventory. Respondents reported their attendance at each of six hospital supports that may serve to mitigate moral distress in frontline staff. Analyses compared outcomes across respondent characteristics and hierarchical linear regression evaluated individual, ICU, hospital, and regional effects.

Setting: Eligible ICUs were PICUs and level-3 neonatal ICUs in Canada.

Subjects: Eligible participants had worked in the participating ICU for more than 3 months.

Interventions: None.

Measurements and main results: We identified 54 eligible ICUs from 31 hospitals. Forty-nine Canadian neonatal ICUs and PICUs (91%) contributed 2,852 complete responses for a 45.2% response rate. Most respondents were nurses (64.9%) or from a neonatal ICU (66.5%). The median and interquartile range Moral Distress Scale-Revised were 79 (52-113); 997 respondents (34.2%) had Moral Distress Scale-Revised scores greater than or equal to 100, and 234 respondents (8.3%) strongly agreed that work caused them significant moral distress. Nurses had a median (interquartile range) Moral Distress Scale-Revised score of 85 (57-121), 19 points higher than physicians and 8 points higher than respiratory therapists (p < 0.0001). Moral Distress Scale-Revised scores increased from 53 (35-79) for those working in ICU less than 1 year to 83 (54-120) in those working in ICU more than 30 years (p < 0.0001); 22.5% reported high degrees of depersonalization, which was associated with moral distress (p < 0.0001). Variability in Moral Distress Scale-Revised scores was explained by individual-level (92%), hospital-level (5%), and ICU-level effects (1%). Frequency of participation in potentially mitigating hospital supports had small effects (< 10 points) on mean Moral Distress Scale-Revised scores.

Conclusions: Moral distress is common in clinicians working in ICUs for children. Addressing moral distress will require interventions tailored to individuals in higher-risk groups.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Canada
  • Child
  • Cross-Sectional Studies
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Morals
  • Stress, Psychological* / diagnosis
  • Stress, Psychological* / epidemiology
  • Surveys and Questionnaires