Publication
Impacts of Ethical Dilemmas and Moral Distress in Pediatric Hematology Oncology Nurses
Madni A, Levine D, Sawyer K, Azzi Y, Mandrell B, Li Y, Ashcraft E, Boggs J, Acharya R, Caples M, Gattuso J, Shoulders L, Johnson L · Pediatric Blood and Cancer · 2025
Purpose To assess the level of moral distress (MD) and perceptions of ethical climate among pediatric hematology/oncology (PHO) nurses and to identify bioethics topics where increased education was desired. Methods In this cross-sectional study, we administered the 26-item Swedish Moral Distress Scale-Revised (sMDS-R), specifically revised and validated for pediatric oncology, in conjunction with the Clinical Ethics Needs Assessment Survey (CENAS). Electronic surveys were sent to inpatient and outpatient PHO nurses. Analysis included descriptive statistics, Spearman correlation, and the Mann–Whitney U test. Results Of 123 nurse respondents, the overall mean MDS-R score was 2.75 (range: 0–16). Distressing encounters occurred infrequently (frequency mean 0.96, range: 0–4), resulting in relatively low distress (mean 2.24, range: 0–4). The scenarios resulting in the highest overall MD included performing painful procedures on children (2.46), lack of meaningful conversations due to time constraints (2.41), and poor team communication (2.68). Inpatient nurses reported higher levels of MD compared to outpatient nurses (p = 0.0002). The overall CENAS score was greater than 3 (range: 1–4), suggesting a positive ethical climate. There was a moderate negative relationship between sMDS-R combined scores and CENAS scores (p < 0.0001). Inpatient nurses reported a less positive ethical climate compared to outpatient nurses (p = 0.01). Nurses expressed a need for additional ethics education around withholding/withdrawing of life-sustaining treatments, providing end-of-life care, and working with challenging patients/families. Conclusions Although the ethical climate was overall positive, several clinical situations appear to result in higher moral distress despite their infrequency, especially on inpatient units. Additional resources and education in navigating ethical dilemmas were requested by the nurses.
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