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Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians’ involvement in patients’ end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare s...

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Autores principales: Palmer, Jennifer A., Mccullough, Megan, Wormwood, Jolie, Soylemez Wiener, Renda, Mesfin, Nathan, Still, Michael, Xu, Chris S., Linsky, Amy M.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10503769/
https://www.ncbi.nlm.nih.gov/pubmed/37713379
http://dx.doi.org/10.1371/journal.pone.0291542
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author Palmer, Jennifer A.
Mccullough, Megan
Wormwood, Jolie
Soylemez Wiener, Renda
Mesfin, Nathan
Still, Michael
Xu, Chris S.
Linsky, Amy M.
author_facet Palmer, Jennifer A.
Mccullough, Megan
Wormwood, Jolie
Soylemez Wiener, Renda
Mesfin, Nathan
Still, Michael
Xu, Chris S.
Linsky, Amy M.
author_sort Palmer, Jennifer A.
collection PubMed
description Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians’ involvement in patients’ end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19’s catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians’ demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents’ demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during “peak-Covid,” and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53–7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18–0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22–0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.
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spelling pubmed-105037692023-09-16 Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19 Palmer, Jennifer A. Mccullough, Megan Wormwood, Jolie Soylemez Wiener, Renda Mesfin, Nathan Still, Michael Xu, Chris S. Linsky, Amy M. PLoS One Research Article Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians’ involvement in patients’ end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19’s catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians’ demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents’ demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during “peak-Covid,” and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53–7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18–0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22–0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care. Public Library of Science 2023-09-15 /pmc/articles/PMC10503769/ /pubmed/37713379 http://dx.doi.org/10.1371/journal.pone.0291542 Text en https://creativecommons.org/publicdomain/zero/1.0/This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 (https://creativecommons.org/publicdomain/zero/1.0/) public domain dedication.
spellingShingle Research Article
Palmer, Jennifer A.
Mccullough, Megan
Wormwood, Jolie
Soylemez Wiener, Renda
Mesfin, Nathan
Still, Michael
Xu, Chris S.
Linsky, Amy M.
Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title_full Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title_fullStr Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title_full_unstemmed Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title_short Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19
title_sort addressing clinician moral distress: implications from a mixed methods evaluation during covid-19
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10503769/
https://www.ncbi.nlm.nih.gov/pubmed/37713379
http://dx.doi.org/10.1371/journal.pone.0291542
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