Moral distress and ethical climate in pediatric oncology care impact healthcare professionals' intentions to leave

To assess perceptions of ethical climate, experiences of moral distress, and intentions to leave among healthcare professionals in Nordic pediatric oncology care.

autonomy, are challenging when caring for children with cancer. Some ethical challenges arise when healthcare professionals are not allowed to tell the truth about the poor prognosis, when they must perform procedures against children's wishes, or when disagreements about a transition from curative to palliative care arise. 3 Situations when healthcare professionals cannot act according to their ethical judgment can cause moral distress. 4 Moral distress often arises when one cannot provide proper, safe care to a patient, 5 and it can cause burnout, 6 frustration, bad conscience, emotional numbness, high blood pressure, sleeping problems, 7 and intention to leave. 8 Whilst studies over the past 2 decades have explored moral distress in various healthcare settings, the focus has been on intensive care. 9,10 Healthcare professionals' ethical behaviors are not only influenced by their personal values, but also by the ethical climate, that is, their perceptions of the right behavior at the workplace. 11 A negative ethical climate can encourage healthcare professionals to take shortcuts when caring for patients, to justify unethical behavior by finding excuses, and to contribute to deterioration of morality. 12 Because of high staff turnover and the many ethical challenges in pediatric oncology care, ethical climate and moral distress should be further explored within this specialty. It is important to identify barriers to ethical conduct that might generate moral distress in healthcare professionals. The aim of this study was to assess perceptions of ethical climate, experiences of moral distress and intentions to leave in Nordic pediatric oncology care.
The specific research questions were.

| Design
This was a cross-sectional survey study.

| Setting
Pediatric oncology care centers in Sweden, Finland, Denmark, Norway and Iceland.

| Instruments
Prior to the study, two existing instruments, the Hospital Ethical Climate Survey-Shortened, HECS-S 13,14 and the Moral Distress Scale-Revised, MDS-R, 14,15 were modified and translated into Swedish with permission from the developers. These Swedish versions were subsequently translated into Finnish, Danish, Norwegian and Icelandic. The translation, adaptation and validation involved multiple techniques: two separate bilingual translators, focus-groups to synthesize versions and cognitive interviews to test construct validity. The process has been described in detail in previous articles. 16,17

| The Swedish Hospital Ethical Climate Survey-Shortened
The Swedish version 18,19 consists of 21 items that describe relations, ethical practices and attitudes at a hospital. Respondents are asked to assess all items based on how often they perceive the described items to be true, on a scale from 1 (almost never) to 5 (almost always). Three items that describe relations between registered nurses and nursing assistants were removed from the Danish and Norwegian translations, because there were no nursing assistants at those centers. The occupation was quite rare at the Finnish centers and in Iceland, and since most nursing assistants (91%) worked at the Swedish centers, these three items were not included in the present study. The sum of the remaining 18 item scores represents a HECS-S score, which ranges from 18 to 90. Higher scores indicate positive perceptions of ethical climate.

| The Swedish Moral Distress Scale-Revised
The Swedish version consists of 26 items that describe clinical situations which can be experienced as morally distressing. Respondents are asked to assess these items based on how disturbing they would experience the situation (intensity) and how often they have experienced the situation (frequency), on a scale from 0 (not at all/never) to 4 (very disturbing/often). For each item, frequency scores are multiplied by intensity scores to get a moral distress level (with a possible range of 0-16). Thereafter, these new scores are added up, and the sum (with a possible range of 0-416), represents a MDS-R score. Higher scores indicate higher levels of moral distress.

| Intention to leave
Two additional items are linked to the MDS-R, asking about respondents' intentions to leave their employment due to moral distress. 14 1068 -VENTOVAARA ET AL.

| Statistical methods
All analyses were run in International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) Statistics 27. Missing value analysis was performed to detect incomplete questionnaires, and respondents with more than 10% unanswered items per scale motivated exclusion from the analysis of that specific scale. Demographic characteristics of the respondents are reported as counts and percentages. As the HECS-S and the MDS-R provide ordinal, Likert data, the results are reported with medians with interquartile range (IQR) (Q1-Q3). Non-parametric tests, Mann-Whitney U and Kruskal-Wallis H, were applied to study differences between groups. Due to extreme outliers, Spearman's rank correlation was calculated to detect associations between scales. All pvalues <0.05 were considered to provide evidence on statistical significance.

| RESULTS
Altogether, 970 questionnaires were distributed to all registered nurses, nursing assistants and physicians who were working in direct patient care at the time-point of the data collection, and 58% of them (567/970) completed the survey. Those who did not work in direct patient care, or had a profession other than listed above, were excluded, leaving a total of 543 responses from 384 registered nurses, 68 nursing assistants, and 91 physicians. The demographic characteristics can be seen in Table 1. In addition to nine respondents with more than 10% missing data points, Iceland (n = 24) was entirely excluded from the ethical climate analysis because the response options "almost always" and "almost never" had been misplaced in T A B L E 1 Demographic data of the healthcare professionals included in the study (N = 543).

| Ethical climate
Most healthcare professionals perceived ethical climate as positive.
Median scores for the individual items are illustrated in Figure 1.
Despite some considerable individual variations, the overall HECS-S score, on a scale from 18 to 90, was 72 (IQR 65-78). In general, men had significantly more positive perceptions compared to women (U (508) = 11,668, p < 0.05), as did the physicians compared to nursing staff (H 2 = 21.405, p < 0.001), as seen in Table 2. Ethical climate varied rather within countries than between countries, and the differences between centers were statistically significant One third of the healthcare professionals perceived that they could most often practice care as they thought it should be practiced (157/510; 31%). However, the percentage was lower than 31% at six centers out of eight with a median HECS-S score below the average of 72. At the center with a median of 66, none of the healthcare professionals perceived that they most often could practice care as it should.
As mentioned above, Iceland was not included in ethical climate analysis.

| Moral distress
The median disturbance (intensity) was 3 (IQR 3-4) and frequency 1 T A B L E 2 Respondent characteristics, the median HECS-S and the MDS-R scores, and the p-values for the differences between groups.

| Intention to leave
Most healthcare professionals, 73% (399/543), had never considered leaving their job in healthcare due to moral distress. Almost 5% (25/ 543) had resigned in the past because of moral distress, and at the time point of the survey, nearly 6% (30/543) were considering this. It was more common at some centers than at others; the portion of healthcare professionals who considered leaving varied from 0% to 29% between centers. Intentions to leave were reported almost exclusively by nursing staff: not a single physician had considered leaving in the past, and only one did so at the moment. Intentions to leave were divided evenly between those who had continued education (6%) and those who did not (6%), and similarly, between those who had shorter (5%) and longer (6%) work experience in pediatric care.  [26][27][28] An Italian study linked moral distress with low nurse-to-patient ratios, suggesting fewer patients per nurse to alleviate the problem. 29 According to Lamiani 29 some organizational factors may impact moral distress more than individual factors. Dryden-Palmer et al. 30 found that moral distress varied more between hospitals, than between individual intensive care units within the hospital.

HECS-S scores
While the present study was conducted only at one unit of each hospital, the variances were greater between the units (hospitals) than between countries, which suggests that institutions do have an influence on moral distress. The means of an individual unit to impact workforce deployment and healthcare delivery system may be limited to its organization's resources and policies. Therefore, organizational and system-level actions may be needed to mitigate moral distress 10,31 and to ensure safe staffing levels, adequate workloads and continuity of care.
Higher MDS-R scores were associated with intentions to leave due to moral distress. This finding is in line with several previous studies. 8,28,32 Although moral distress is not the major reason why healthcare professionals leave their jobs, it should not be disparaged.
Not only is it burdensome for the healthcare professionals in question, but staff turnover also impairs the collective competence, 33 jeopardizing the high-quality care that every child with cancer has a right to. Prior research has established a strong relationship between ethical climate and nurses' job satisfaction. 24 It accords with both recent 34

| Study limitations
One potential weakness of this study is the long data collection  39 The MMD-HP describes even situations not included in the MDS, for example, compromised care due to demands for excessive documentation, that was found to be the most frequent cause of moral distress among pediatric residents and hospitalists in a recent study. 40 However, to allow comparisons between study sites, the MDS-R was applied throughout the present study, after it had been modified for the target population. 18 Questionnaires can hardly capture all dimensions of ethical climate and moral distress, and qualitative approaches should be applied to deepen the understanding and to supplement quantitative findings.

| Clinical implications
As only one third of the healthcare professionals could most often practice care the way they though it should be practiced, it can be reasonably assumed that action is needed to improve working conditions. The findings suggest that interventions to prevent and alleviate moral distress should focus on safe staffing levels and on ensuring continuity of care. Adequate staffing levels and other attempts to reduce moral distress could also influence nurses' intentions to leave and thereby affect staff retention. The safe, stable relationships with nurses and physicians would probably also benefit all children with long-term illness.