International Journal of Pediatric Otorhinolaryngology 136 (2020) 110138

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

2016 ESPO Congress

Moral distress in pediatric otolaryngology: A pilot study☆ T

a,b,∗ a,b c,d a,b
Andrew J. Redmann , Matthew Smith , Dan Benscoter , Catherine K. Hart
a
Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, USA
b
Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
c
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
d
Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives:
Moral distress
Pediatric otolaryngology 1. Determine the prevalence of moral distress for pediatric otolaryngologists at a tertiary medical center
MDS-R 2. Evaluate the impact of demographic variables on moral distress levels.
Subjects/methods: Moral distress is defined as “when one knows the right thing to do, but institutional con-
straints make it nearly impossible to pursue the right course of action”. The Moral Distress Survey-Revised (MDS-
R) is a validated 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously dis-
tributed to pediatric otolaryngology faculty and fellows at a tertiary institution. Descriptive statistics, bivariate
and multivariate analysis were performed.
Results: Response rate was 89% (16/18). Overall MDS-R score was 40 (range 14–94), which is lower than that
found in the literature for pediatric surgeons (reported mean 72), pediatric intensivists (reported means 57–86),
and similar to pediatric oncologists (reported means 42–52). Fellows had a significantly higher level of moral
distress than faculty (mean 69 vs. 26, p < 0.05). Factors leading to higher degrees of distress involved com-
munication breakdowns and pressure from administration/insurance companies to reduce costs.
Conclusion: Pediatric Otolaryngologists at our institution have lower degrees of moral distress compared to other
pediatric subspecialists. Fellows had higher levels of distress compared to faculty. Further research is necessary
to determine degrees of distress across institutions and to determine its impact on the wellness of pediatric
otolaryngologists.

1. Introduction compared to pediatric intensivists and emergency physicians [9].

Moral distress is defined as “when one knows the right thing to do,
but institutional constraints make it nearly impossible to pursue the
right course of action” [1]. Since the term was coined by Jameton in
1984, the concept has been well described in the nursing literature,
specifically with respect to involvement in care at the end of life [2–7].
More recent literature has focused on moral distress in physicians, with
a specific interest in those who care for critically ill pediatric and
neonatal patients [8–11]. In particular, a recent survey of pediatric
surgical trainees illustrated a high degree of moral distress while caring
for patients during training [8]. One recent cross sectional study sug-
gested that surgeons in particular may have a high level of moral dis-
tress compared to other fields of pediatric medical care such as medical
oncology and general pediatrics, and similar levels of moral distress
To this point, there has been no exploration of the prevalence or
impact of moral distress in Otolaryngology or pediatric otolaryngology.
There has been limited work in pediatric healthcare in general, and
much of this has been limited to critical care settings [3,6,9,10]. Our
approach was to use a validated survey for the measurement of moral
distress (the Moral Distress Survey-Revised, or MDS-R) to measure
baseline moral distress levels in pediatric otolaryngologists.
2. Methods
Institutional review board approval was obtained from the
Cincinnati Children's Hospital Medical Center (CCHMC) Institutional
Review Board prior to project initiation. The revised moral distress
scale (MDS-R) is a validated survey to measure moral distress in those

☆
Meeting Information: Presented as an oral presentation at the Society for Ear, Nose and Throat Advances in Children (SENTAC), 12/6/19, San Diego CA.
∗
Corresponding author. Otolaryngology-Head & Neck Surgery, Cincinnati Children's Hospital Medical Center Division of Pediatric Otolaryngology, 3333 Burnet
Ave, OSB-3, Cincinnati, OH, 45229, USA.
E-mail address: Andrew.redmann@gmail.com (A.J. Redmann).

https://doi.org/10.1016/j.ijporl.2020.110138
Received 23 March 2020; Received in revised form 8 May 2020; Accepted 22 May 2020
Available online 29 May 2020
0165-5876/ © 2020 Elsevier B.V. All rights reserved.
A.J. Redmann, et al.
caring for pediatric populations [9,10]. The MDS-R includes 21 state-
ments describing situations known to cause moral distress in clinical
practice, and is scored on a 4-point Likert scale for both frequency and
intensity (appendix 1). The survey is then scored by multiplying the
frequency and intensity scores, thus each individual statement has a
range of scores from 0 to 16. The sum of all 21 products gives an overall
score from 0 to 336. We also queried demographic information in-
cluding sex, age, fellowship training status, and years of practice. Three
additional questions regarding institutional support for morally dis-
tressing situations were also included.
The survey was administered to all pediatric otolaryngology faculty
(N = 13) and clinical pediatric otolaryngology fellows (N = 5) at
CCHMC at the time of survey distribution (January 2019). The primary
investigators (CKH, AJR) did not complete the survey in order to limit
bias. Surveys were given in paper format to faculty and fellows, and
returned in an envelope with no identifiers. Survey responses were then
entered into a secure REDCap database [12,13]. REDCap (Research
Electronic Data Capture) is a secure, web-based software platform de-
signed to support data capture for research studies, providing 1) an
intuitive interface for validated data capture; 2) audit trails for tracking
data manipulation and export procedures; 3) automated export proce-
dures for seamless data downloads to common statistical packages; and
4) procedures for data integration and interoperability with external
sources.
Analysis was carried out using PSPP statistical software (Boston,
MA). Descriptive statistics were computed for all demographic data.
Two tailed t-test was used to compare continuous variables between
groups. Power analysis was performed using a t-test, with an alpha of
0.05, and N = 11 (faculty) and N = 5 (fellows). With an effect size of 2,
the power was 0.99 to detect differences between the faculty and fellow
responses. Comparison of categorical data was carried out using
Pearson's chi-square analysis to analyze bivariate associations between
demographics and survey responses. All statistics were two-tailed and
considered statistically significant if p < 0.05. The primary outcome
measure was the MDS-R score for the studied population.
3. Results
A total of 18 surveys were distributed, and 16 responses were re-
corded (response rate 89%). Of the responses, 5/5 fellows completed
the survey, and 11/13 of faculty responded. Demographics of the re-
spondents are shown in Table 1. Overall MDS-R scores ranged from 14
to 94, with a mean score of 40. There were no significant differences in
overall MDS-R scores based on age or sex. Clinical fellows had a mean
MDS-R score of 69 (range 41–94), which was higher (P = 0.03) than
faculty, who had a mean MDS-R score of 26 (range 14–57). These
Table 1
Demographics.
Sex N (%)
Male 11 (69)
Female 5 (31)
Age
30–39 8 (50)
40–49 2 (13)
50–59 3 (19)
> 60 3 (19)
Fellow
Yes 5 (32)
no 11 (69)
Years of practice
< 1yr 3 (19)
1–4 yrs 4 (25)
5–9 yrs 1 (6)
10–15 yrs 2 (13)
16–20 yrs 2 (13)
> 20 yrs 4 (25)
2
International Journal of Pediatric Otorhinolaryngology 136 (2020) 110138
Table 2
Mean MDS-R scores by faculty status.
Characteristic MDS-R score (range) P value
Fellow 26 (41–94) < 0.01
Faculty 69 (14–57)
1Moral distress in Peds Oto.
findings are reported in Table 2.
There were seven specific statements where fellows had higher
moral distress scores than faculty, including “Follow the family's wishes
to continue life support even though I believe it's not in the best interest
of the child” (4.7 vs. 1.3, p = 0.01), “Initiate extensive life-saving ac-
tions when I think they only prolong death” (4.6 vs. 1.1, p = 0.03),
“Carry out orders for what I consider to be unnecessary tests and
treatments” (4.0 vs 1.8 p = 0.01), “Continue to participate in care for a
hopelessly ill child who is being sustained on a ventilator, when no one
will make a decision to withdraw support” (5.6 vs 1.6 p = 0.02),
“Follow the family's wishes for the child's care when I do not agree with
them, but do so because of fears of a lawsuit” (2.7 vs 0.6, p = 0.02),
“Assist a physician who in my opinion is providing incompetent care”
(4.2 vs 1.2, p = 0.01), and “Ignore situations in which parents have not
been given adequate information to insure informed consent” (3.3 vs
0.4, p = 0.05). There were no other survey questions with significant
differences between faculty and fellows.
One statement elicited a higher score for both faculty and fellows
compared to the remainder of the survey. “Witnessing diminished pa-
tient care quality due to poor team communication”. Respondents re-
ported that this occurred more often (frequency score mean of 1.7) than
any other statement, and it was moderately distressing when it did
occur (severity score of 2.9). One other statement was noted to be se-
verely distressing (severity score mean of 3.1) when it did occur, but
was relatively rare (frequency score 0.8): “Provide less than optimal
care due to pressures from administrators or insurers to reduce costs”.
There were a number of questions where the product of frequency
and severity was less than one, with many respondents recording that
these events “never occurred”. These statements are listed in Fig. 1.
4. Discussion
Moral distress is important to physicians, patients and health sys-
tems, as it leads to increased rates of burnout [14,15], lower staff re-
tention rates [3,9], and decreased job satisfaction [10]. Burnout cor-
relates with physicians’ perception of providing poorer quality care
[16–18], and previous work has posited that moral distress is an un-
derlying cause of burnout [10,14]. Increased levels of burnout in phy-
sicians and nurses costs health systems a significant amount, with a
recent study suggesting that burnout in the Canadian health system
leads to a cost of over $213 million (CDN) in future service reductions
due to early retirement and decreased clinical productivity [19]. Un-
derstanding moral distress, one of the potentially modifiable causes of
burnout, is an opportunity to both improve physician satisfaction, as
well as decrease health care costs. Our work is the first exploration of
moral distress in otolaryngologists.
In our survey, fellows had a higher degree of distress compared to
faculty, with seven statements providing the majority of this difference.
These statements primarily centered on pursuing aggressive care in a
setting where the provider does not think it is appropriate action.
Previous work has found significantly higher burnout scores in trainees
compared to faculty and department chairmen (lowest rates of burnout)
in otolaryngology, and the underlying reasons may be similar [20]. It
may be that higher degrees of distress in fellows center on a perceived
lack of control in difficult situations, especially if there is disagreement
with an attending physician about the correct action. Fellows and early
career faculty also have a relative lack of experience with difficult
A.J. Redmann, et al.
Fig. 1. Statements of limited applicability to pediatric otolaryngology.
clinical situations, which may lead to higher degrees of uncertainty in
defining a “correct” decision. Finally, it may be that differences in the
volume of bedside care provided by fellows compared to faculty may
lead to higher emotional investment in particular cases and increase
distress. This has previously been proposed as a reason for higher de-
grees of moral distress in intensive care nurses as compared to intensive
care physicians [6,8–10]. For the above reasons, it may be beneficial to
incorporate discussions about the best way to handle distressing si-
tuations within otolaryngology resident and fellowship training pro-
grams. This may be with senior mentors who are able to draw on past
experience to guide junior physicians, or through setting aside a formal
time for discussion of emotionally difficult cases, such as has been de-
scribed in the Schwartz Rounds program [21,22].
The most concerning statement for both faculty and fellows cen-
tered on communication breakdowns leading to poor patient care. This
has been well described in the literature, with breakdowns in commu-
nication reported by almost 40% of inpatients [23,24]. Consistent with
previous research, our findings suggest that this is a potential area of
intervention in the future. One particular situation that may cause
moral distress in pediatric otolaryngologists is the decision-making
process surrounding tracheostomy placement for long term ventilator
support in children with terminal diagnoses and poor prognoses [25].
Communication around this situation often involves multiple services
(pediatric or neonatal ICU, pediatric surgery, palliative care and
others), which complicates clear lines of communication, and may be a
particular area where poor communication leads to distress for pedia-
tric otolaryngologists.
There were a number of questions with very low applicability to
pediatric otolaryngology at our institution (Fig. 1). Many of these
questions were reported as “never occurring”, which is congruent based
on the nature of pediatric otolaryngology, as many of these statements
refer to situations that do occur in an ICU setting without otolar-
yngology input. This information may assist in allowing the construc-
tion of a more concise instrument that better focused on the issues that
pediatric otolaryngologists experience in day to day practice. The lack
of these situations being part of everyday practice may also be a reason
why pediatric otolaryngologists have lower.
MDS-R scores compared to pediatric surgeons (reported mean 72),
or pediatric intensivists (reported means 57–86), as these physicians are
closely involved with acute care at the end of life, which is uncommon
for pediatric otolaryngologists [8–10].
Our study, like all small surveys, has a number of limitations. Most
importantly, our sample size is small and these findings are only re-
presentative of a single division at a single institution. Any conclusions
must be tempered due to these limitations. However, this is the first
data on moral distress in otolaryngology, and this pilot study raises
questions that point to the need for a nationwide survey to evaluate if
the findings here are generalizable.
3
International Journal of Pediatric Otorhinolaryngology 136 (2020) 110138
5. Conclusion
Our data suggest that at one tertiary care institution, pediatric
otolaryngologists have a low degree of moral distress compared to other
pediatric inpatient physicians, but that fellows may have a higher de-
gree of moral distress compared to faculty. Larger scale study is ne-
cessary to make more robust conclusions about baseline levels of moral
distress in pediatric otolaryngology, as well as to determine if there are
different demographic factors that affect moral distress scores.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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