A growing body of empirical research points to high levels of frustration, anxiety, fear, anger, sorrow, self-doubt, and guilt that health care providers experience when they feel powerless to practice according to their ethical standards. These emotions reflect moral distress which develops when professionals believe they know what is the right thing to do but feel powerless to act according to their values because of internal or external constraints. Research, including our own, shows that this problem has reached alarming prevalence in Intensive Care Units (ICUs), particularly in nurses. Threats to moral integrity in ICUs are usually driven by end-of-life controversies, inconsistent care plans, and pressure to reduce costs. The consequences range from diminished workplace satisfaction to absenteeism, burnout, attrition, workplace incivility, increased adverse events, and ethical numbness over time. Yet there is almost no empirical evidence about how to prevent or treat moral distress.

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Led by an international multi-disciplinary team of clinicians and researchers from the clinical and social sciences, this project will build on academic studies of moral distress to effectively address this issue at both individual and organizational levels. To meet our goal, we will apply the moral conflict assessment (MCA) and intervention process developed and pre-tested by Dr. Chevalier, in partnership with Dr. Thibeault (co-applicants), Providence Health Care Research Institute (Vancouver), and the Centre for Practitioner Renewal at Providence Health Care. The MCA approach builds on existing knowledge about participatory action research and moral distress. It is also innovative in that it guides participants in unpacking moral conflict from other concerns that often coalesce in real-life settings, including perceived gains or losses in ‘self-interest’ and ‘self-realization’, an issue overlooked by many other approaches. We will test and model this novel approach to translating knowledge into action by engaging health care providers and knowledge-users from two tertiary and two community ICUs (an estimated 400 ICU administrators, physicians, nurses, respiratory therapists, and other health care professionals) in applying the MCA process to better understand and overcome moral distress situations.

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To ensure that this process is ‘built-in’ rather than ‘built-on’ existing ICU workflows, MCA discussions will be facilitated by five existing ‘action-learning services’ within each hospital that are already mandated to address this kind of problem: 1) ethics education, 2) ethics consultations, 3) clinical supervision, 4) unit-based ethics conversations, and 5) ethical policy development. Structured discussions (using the nine-step MCA process adapted to each service) will take place at the beginning, half-way into, and at the end of the project, over two years. The effect of the MCA process on moral distress will be monitored and evaluated in each ICU using a highly innovative, interactive web-based methodology for collaborative data entry and analysis by each participant; aggregate data will be available for broader use and dissemination after project completion. The MCA and measurement processes will also be evaluated using focus groups at each hospital site. This project is thus intended to be educative and empowering for all parties, reflecting a dynamic approach in which problem identification, planning, action, and evaluation are closely interlinked.