"Measuring Moral Distress and Moral Distress Consultation: A Tiered Investigation"

Abstract
Background: Moral distress (MoD) in healthcare providers (HCPs) can signal problems within healthcare systems that impact patient care quality, team functioning and organizational efficacy. Moral distress consultation (MDC) is one system-level intervention capable of alleviating MoD. MDC participants, its consultants, and their unit- and organizational-based leadership teams are key stakeholders in MDC and so offer unique perspectives about MDC effectiveness and sustainability.
Purpose: The primary aim of this study was to determine the experience of MDC from its stakeholders. A secondary aim was to develop a beginning evaluation framework for MDC.
Methods: A concurrent multi-method design was completed at two academic medical centers with long-standing, active MDC services. To provide contextual MoD data, MDC participants were asked to rate their MoD and identify its cause(s) before and after MDCs occurring during the study period. Data were collected using an adapted, real-time MoD measurement tool. In parallel, semi-structured interviews were conducted with a sample of each institution’s MDC consultants and unit- and organization-based leadership teams. These interviews were focused on overall experiences with MDC and to better understand the requirements needed when considering evaluation tool development. Deidentified transcripts were analyzed in Nvivo software using both inductive and deductive coding strategies. While this was being completed, a researcher of similar standing to the primary author was sent all consultant transcripts and a subset of leadership transcripts for analysis via open coding. Both coding frames were compared, an intercoder agreement developed and thematic maps constructed. These maps were then iterated with each institution’s MDC directors (and this study’s co-Investigators) for final analysis.
Results: Twenty MDCs were held during the study period. Participants who completed pre- and post-surveys (n = 22) reported an average pre-MDC MoD score of 5.9 (SD = 2.2) and 5.3 (SD = 2.7) after (t (21), p = .31). Participants indicated MoD causes ranging from team- and communication focused prior to consultation to more system-focused following consultation. Ten MDC consultants and eight unit and organizational-based leaders were interviewed. Both groups indicated MDC was high-value and identified a need for clear and consistent MoD and MDC education plans. Consultants added that collaboration with organizational leaders was integral to MDC success. Both groups also responded to the importance of qualitative stories from MDC participants and how quantitative measures were difficult and not well-standardized.
Conclusion: MDC participants indicated MoD was present during the study period and their selected causes suggest MDC may help facilitate team communication and reveal more system-level issues. Themes gathered from consultant and leader interviews help to outline a beginning framework an organization could use to start, sustain, and evaluate MDC, including a focus on MoD and MDC education, collaboration between leaders and MDC consultants, and incorporating qualitative data into success metrics.