title: Moral distress within neonatal and paediatric intensive care units: a systematic review.
abstract: OBJECTIVE
  To review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).
  
  
  METHODS
  Pubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care.
  
  
  RESULTS
  13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly 'burdensome' and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating 'aggressive care'. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations.
  
  
  CONCLUSIONS
  Moral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.
authors.affiliation: Neonatal Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Trisha
authors.initials: T
authors.lastname: Prentice
authors.affiliation: Division of Neonatology and Clinical Ethics, University of Montreal, Montreal, Quebec, Canada.
authors.forename: Annie
authors.initials: A
authors.lastname: Janvier
authors.affiliation: Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.
authors.forename: Lynn
authors.initials: L
authors.lastname: Gillam
authors.affiliation: Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Davis
mesh_terms: D001293:Attitude to Death; D006801:Humans; D007363:Intensive Care Units, Neonatal; D015278:Intensive Care Units, Pediatric; D008505:Medical Staff, Hospital / Q000523:psychology*; D009014:Morals; D000072222:Nurses, Pediatric / Q000523:psychology*; D009784:Occupational Diseases / Q000209:etiology*; D013315:Stress, Psychological / Q000209:etiology*
keywords: Decision-making; Ethics; Intensive Care; Moral Distress; Palliative Care