Moral distress in neonatologists working in neonatal intensive care units in Greece: A qualitative study
Authors: Deligianni Maria , Voultsos Polychronis , Tzitiridou-Chatzopoulou Maria K. , Drosou-Agakidou Vasiliki , Tarlatzis Vasileios 
Published: November 2022

Abstract
Background
Working as neonatologist in the neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. Neonatologists’ periviable resuscitation or medical futility decisions involve an attempt to determine the infant’s best interest and strike a balance between infant’s best interest and respect for parents' autonomy. This may cause neonatologists to develop high levels of moral distress, especially when caring for extremely premature infants (EPIs) under high levels of prognostic uncertainty and without guidelines. In Greece, few qualitative studies are focusing primarily on neonatologists and provide little insight into how neonatologists working in the NICU make or perceive their decisions. Moral distress among neonatologists working in the NICU is a topic that is still understudied and warrants further exploration.
Methods
This was a prospective qualitative study that used semistructured interviews of twenty neonatologists who had been working in NICUs in Greece for at least one year. The study was conducted between March 2022 and August 2022. A thematic analysis of the data was performed.
Results
A variety of distinct themes and subthemes emerged from the interview data analysis. Neonatologists are confronted with moral conflicts perceived as irreconcilable. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek out a third-party support for their decisions to reduce their decision uncertainty. In addition, from the interview data analysis emerged multiple predisposing factors that further increase the neonatologists’ uncertainty distress or let it continue elevated, as well as multiple predisposing factors that may be associated with either neonatologists’ constraint distress or their uncertainty distress. Among the predisposing factors that further increase the neonatologists’ uncertainty distress or let it continue elevated have been identified, the lack of neonatologist’s previous experience, the lack of clear and adequate clinical practice guidelines / recommendations/ protocols, the shortage of healthcare resources, the fact that in the context of neonatology best interest and quality of life are determined with difficulty, the administration of an off-label medication and the need for making decisions in a short time frame. NICU directors, neonatologists’ colleagues working in the same NICU and parental wishes and attitudes have been identified as predisposing factors that may be associated with either neonatologists’ constraint or their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time
Conclusions
We concluded that neonatologists’ moral distress should be conceptualized in the broad sense of the term and is strictly associated with multiple predisposing factors. It is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with prior literature. However, we identified some nuances that are of practical importance. The results of this study support the need for establishing Institutional Ethics Committees in every healthcare setting and make neonatologist aware of them. Furthermore, the results of this study support the need to make professional psychological counselling available in every NICU. Ultimately, the results of this study may serve as a starting point for future research.