'Are we doing the right thing?' Moral Agency in Paediatric Healthcare: Healthcare professionals' actions in response to moral conflict, and the associated enablers, barriers and outcomes

Paediatric health care professionals (HCPs) may experience moral conflict if they are required to deliver care which is not aligned with their moral values. While much research has been conducted to understand the causes and effects of situations which cause moral conflict, how HCPs actually act in these situations has received scant research attention. This study addresses this gap. A qualitative research approach incorporating the Critical Incident Technique (CIT) was used to explore the actions of paediatric nurses and doctors when faced with moral conflicts, the enablers and barrier of these actions, and participants’ perceptions of the outcomes of their actions. Semi-structured interviews were held with a sample of nurses and doctors (n=19) from a large tertiary children’s hospital in Ireland. Data was analysed using a process of thematic analysis, underpinned by the traditions of CIT. Trustworthiness was enhanced through the provision of a clear audit trail and the use of participants’ voice throughout the findings. The participants’ experiences were reflected in ten overarching themes. The causes of moral conflict were captured in the three themes of Conflicts in decision-making, reconciling their Professional role Vs children’s outcomes and the equitable Use and Allocation of resources. Participants’ moral actions emerged as three themes which involved Questioning Decisions, Seeking alternative approaches and Advocating for the child and family. These actions reflected a preference for facilitating negotiation and consensus with the healthcare team and parents as a means of preventing decisional-conflict and achieving mutually acceptable outcomes. The findings challenge notions of powerlessness and adversarial nurse-doctor representations, and instead revealed participants’ strong sense of moral agency. The enablers and barriers of their moral agency were collectively reflected in the themes of Environment of care factors and Personal factors. Moral agency was enabled by participants’ experience and knowledge and working within positive and respectful professional relationships. In contrast, inexperience, hierarchical decision-making structures or apprehension about jeopardising professional relationships impeded moral agency. The outcomes of participants’ action emerged in two themes: Influencing the outcome for the child, family and professionals, which participants’ judged by the extent to which relationships with these parties were preserved and Influencing self which reflected how they themselves were influenced personally and professionally. The participants’ capacity to take moral action appears to have provided a mediating effect against the negative implications of moral conflicts and contributed to their moral resilience. These findings have implications for theory, practice and education, and support the argument that the exploration of moral conflicts and moral agency should extend beyond the existing focus on barriers to understanding how moral agency can be enabled. The narratives offer numerous suggestions for organisational and clinical processes, ethics supports and educational resources to develop HCPs’ ethical competence and create opportunities for them to collaboratively engage with moral issues. As paediatric healthcare will continue to be characterised by increasing medical and technological advancements, and influenced by wider socio-cultural factors, it is unlikely that the situations which generate moral conflict for HCPs will ever be eliminated. It is crucial therefore, that there is a commitment to establishing an ethical climate which nurtures the moral agency of HCPs, enabling them to positively and constructively engage with the moral issues they encounter in practice.